HOSPITAL_NAME,LAST_UPDATED_ON,VERSION,HOSPITAL_LOCATION,HOSPITAL_ADDRESS,LICENSE_NUMBER|ME,"TO THE BEST OF ITS KNOWLEDGE AND BELIEF, THE HOSPITAL HAS INCLUDED ALL APPLICABLE STANDARD CHARGE INFORMATION IN ACCORDANCE WITH THE REQUIREMENTS OF 45 CFR 180.50, AND THE INFORMATION ENCODED IS TRUE, ACCURATE, AND COMPLETE AS OF THE DATE INDICATED.",,,,,,,,,,,,,,,,
NORTHERN MAINE MEDICAL CENTER,7/2/2024,2.0.0,NORTHERN MAINE MEDICAL CENTER|NORTHERN MAINE MEDICAL CENTER,"194 E MAIN ST, FORT KENT, ME 04743",200052,TRUE,,,,,,,,,,,,,,,,
DESCRIPTION,CODE|1,CODE|1|TYPE,CODE|2,CODE|2|TYPE,CODE|3,CODE|3|TYPE,MODIFIERS,SETTING,DRUG_UNIT_OF_MEASUREMENT,DRUG_TYPE_OF_MEASUREMENT,STANDARD_CHARGE|GROSS,STANDARD_CHARGE|DISCOUNTED_CASH,PAYER_NAME,PLAN_NAME,STANDARD_CHARGE|NEGOTIATED_DOLLAR,STANDARD_CHARGE|NEGOTIATED_PERCENTAGE,STANDARD_CHARGE|NEGOTIATED_ALGORITHM,ESTIMATED_AMOUNT,STANDARD_CHARGE|METHODOLOGY,STANDARD_CHARGE|MIN,STANDARD_CHARGE|MAX,ADDITIONAL_GENERIC_NOTES
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,AETNA,AETNA,2292.71,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,AETNA_MCRADV,AETNA MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,ANTHEM,ANTHEM BLUE CROSS BLUE SHIELD,2221.22,,OUTPAT REV % CHARGES,2289.75,OTHER,2095.49,2465.28,PERCENT OF ITEM CHARGES BASED ON REVENUE CODE
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,ANTHEM_MCRADV,ANTHEM MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,CHOICECARE,CHOICECARE-HUMANA,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,CIGNA_HMO,CIGNA HMO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,CIGNA_PPO,CIGNA PPO,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,GENERATIONS_MCRADV,GENERATIONS MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,HARVARD_PILGRIM,HARVARD PILGRIM HEALTH CARE,2186.7,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,HUMANA_MCRADV,HUMANA MEDICARE ADAVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,MAINE_COMM_HEALTH,MAINE COMMUNITY HEALTH OPTIONS,2268.06,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,"PERCENT OF BILLED CHARGES WITH DRG LIMIT, FLOOR AMOUNT, CEILING AMOUNT"
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,MAINECARE,MAINECARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,MARTINS_POINT,MARTINS POINT HEALTH CARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,MEDICARE,MEDICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,MICMAC HEALTH,MICMAC HEALTH,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,MULTIPLAN,MULTIPLAN,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,TRICARE,TRICARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,TWIN_RIVERS,TWIN RIVERS,2095.49,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,UHC,UNITED HEALTHCARE,2342.02,,OUTPCT LIMIT,2289.75,OTHER,2095.49,2465.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,UHC_MCRADV,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,VACCN,VACCN,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR NEURAXIAL ANES,1967,HCPCS,370,RC,1967,CDM,,OUTPATIENT,,,126.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DAILY EPIDURAL MNGT,1996,HCPCS,370,RC,1996,CDM,,OUTPATIENT,,,126.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) PLATELET RICH PLASMA ANY SITE INCLUDIN,0232T,HCPCS,360,RC,0232T,CDM,,OUTPATIENT,,,832,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,960,RC,7505174,CDM,,OUTPATIENT,,,157.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US FINE NEEDLE ASPIRATION W/ GUIDANCE,10005,HCPCS,402,RC,7043024,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10005,HCPCS,360,RC,10005,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,7505175,CDM,,OUTPATIENT,,,108.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,402,RC,7043025,CDM,,OUTPATIENT,,,430.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY INCLUDING ULTRASOUND GUIDANCE,10006,HCPCS,960,RC,10006,CDM,,OUTPATIENT,,,108.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FINE NEEDLE ASPIRATION BIOPSY WITHOUT IMAGING GUIDANCE FIR,10021,HCPCS,360,RC,10021,CDM,,OUTPATIENT,,,1059,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERC IMG-GUIDED CATH FLUID COLLECTION DRAINAGE,10030,HCPCS,320,RC,7042028,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,981,RC,6235062,CDM,,OUTPATIENT,,,271,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,6230181,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10060,HCPCS,450,RC,100600,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE,10060,HCPCS,450,RC,6230048,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
I AND D ABCESS SIMPLE/SINGLE FAC,10060,HCPCS,360,RC,10060,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,450,RC,6230182,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE,10061,HCPCS,360,RC,10061,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS COMPLICATED/MULTIPLE,10061,HCPCS,450,RC,6230026,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230027,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,450,RC,6230183,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,981,RC,6235063,CDM,,OUTPATIENT,,,206,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST SIMPLE,10080,HCPCS,360,RC,10080,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF PILONIDAL CYST COMPLICATED,10081,HCPCS,450,RC,6230227,CDM,,OUTPATIENT,,,1271,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,450,RC,6230184,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,HCPCS,450,RC,6230028,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10120 INCISION AND REMOVAL FOREIGN BODY SIMP,10120,HCPCS,360,RC,10120,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10120,HCPCS,981,RC,6235064,CDM,,OUTPATIENT,,,479,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION REMOVAL FOREIGN BODY SUBQ TISS COMPL,10121,HCPCS,450,RC,6230232,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES,10121,HCPCS,360,RC,10121,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,981,RC,6230111,CDM,,OUTPATIENT,,,167,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,6230253,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,10140,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,360,RC,7212046,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTIO,10140,HCPCS,450,RC,101400,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,101600,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,,,6230185,CDM,,OUTPATIENT,,,659,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,981,RC,6235065,CDM,,OUTPATIENT,,,311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,960,RC,7505159,CDM,,OUTPATIENT,,,226.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,10160,HCPCS,450,RC,7043008,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDE SKIN UP TO 10% BODY SURFACE,11000,HCPCS,360,RC,11000,CDM,,OUTPATIENT,,,1605,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENTPR,11004,HCPCS,360,RC,11004,CDM,,OUTPATIENT,,,942,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,360,RC,110102,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUS,11010,HCPCS,960,RC,11010,CDM,,OUTPATIENT,,,884,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11011,HCPCS,450,RC,6230245,CDM,,OUTPATIENT,,,1298,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SIT,11012,HCPCS,360,RC,11012,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230192,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,981,RC,6235072,CDM,,OUTPATIENT,,,132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,11042,HCPCS,360,RC,11042,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DER,11042,HCPCS,450,RC,6230029,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND FASCIA 20 SQ CM/<,11043,HCPCS,360,RC,11043,CDM,,OUTPATIENT,,,1605,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT BONE (INCLUDES EPIDERMIS DERMIS SUBCUTANEOUS,11044,HCPCS,360,RC,11044,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,11045,HCPCS,360,RC,7212022,CDM,,OUTPATIENT,,,300,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS DERMI,11046,HCPCS,960,RC,11046,CDM,,OUTPATIENT,,,132.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN SINGLE LESION,11055,HCPCS,360,RC,11055,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LESION 2 TO 4 LESIONS,11056,HCPCS,360,RC,11056,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARING SKIN LSN MORE THAN 4 LESIONS,11057,HCPCS,360,RC,11057,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE,11102,HCPCS,360,RC,11102,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11104,HCPCS,360,RC,11104,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN P,11105,HCPCS,960,RC,11105,CDM,,OUTPATIENT,,,126.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11106,HCPCS,360,RC,11106,CDM,,OUTPATIENT,,,1605,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INCLUDING SIMPLE CLOS,11107,HCPCS,960,RC,11107,CDM,,OUTPATIENT,,,65.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,450,RC,6230189,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,981,RC,6235069,CDM,,OUTPATIENT,,,165,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,761,RC,112000,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11200,HCPCS,750,RC,7210035,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVE SKIN TAGS UP TO 15 LESIONS,11200,HCPCS,360,RC,11200,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA,11201,HCPCS,960,RC,11201,CDM,,OUTPATIENT,,,35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11305,HCPCS,450,RC,11305,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP,11306,HCPCS,360,RC,11306,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE,11311,HCPCS,360,RC,11311,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,360,RC,11400,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11400,HCPCS,490,RC,7210051,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,11401,HCPCS,360,RC,11401,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,11402,HCPCS,360,RC,11402,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11402,HCPCS,510,RC,7210057,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,360,RC,11403,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11403,HCPCS,510,RC,7210058,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,510,RC,7210067,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11404,HCPCS,360,RC,11404,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11406,HCPCS,510,RC,7210059,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM,11406,HCPCS,360,RC,11406,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,510,RC,7210060,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11420,HCPCS,360,RC,11420,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,11421,HCPCS,360,RC,11421,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11421,HCPCS,510,RC,7210061,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11422,HCPCS,510,RC,7210062,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,11422,HCPCS,360,RC,11422,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11423,HCPCS,510,RC,7210063,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM,11423,HCPCS,360,RC,11423,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,360,RC,11424,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11424,HCPCS,510,RC,7210064,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,510,RC,7210065,CDM,,OUTPATIENT,,,112.27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG (,11426,HCPCS,360,RC,7212059,CDM,,OUTPATIENT,,,9041,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,490,RC,7210052,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11440,HCPCS,360,RC,11440,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11441,HCPCS,490,RC,7210053,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM,11441,HCPCS,360,RC,11441,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM,11442,HCPCS,360,RC,11442,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11442,HCPCS,510,RC,7210066,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,510,RC,7210068,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11443,HCPCS,360,RC,11443,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN,11444,HCPCS,510,RC,7210069,CDM,,OUTPATIENT,,,108.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11601,HCPCS,360,RC,11601,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,360,RC,11602,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11602,HCPCS,490,RC,7210055,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11603,HCPCS,360,RC,11603,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11604,HCPCS,360,RC,11604,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS O,11606,HCPCS,360,RC,11606,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11621,HCPCS,360,RC,11621,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11622,HCPCS,360,RC,11622,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM,11623,HCPCS,360,RC,11623,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,960,RC,11624,CDM,,OUTPATIENT,,,586.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK H,11624,HCPCS,360,RC,8020001,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11640,HCPCS,360,RC,11640,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11641,HCPCS,360,RC,11641,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM,11642,HCPCS,360,RC,11642,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11643,HCPCS,360,RC,116430,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11644,HCPCS,360,RC,11644,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EY,11646,HCPCS,360,RC,7212013,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,360,RC,11719,CDM,,OUTPATIENT,,,182,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER,11719,HCPCS,450,RC,6230030,CDM,,OUTPATIENT,,,182,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 1 TO 5,11720,HCPCS,360,RC,11720,CDM,,OUTPATIENT,,,171,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE,11721,HCPCS,360,RC,11721,CDM,,OUTPATIENT,,,171,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,360,RC,11730,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,450,RC,6230187,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE,11730,HCPCS,981,RC,6235067,CDM,,OUTPATIENT,,,166,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,981,RC,6230093,CDM,,OUTPATIENT,,,80,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH AD,11732,HCPCS,960,RC,11732,CDM,,OUTPATIENT,,,104.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230092,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,450,RC,6230188,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,981,RC,6235068,CDM,,OUTPATIENT,,,82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVACUATION OF SUBUNGUAL HEMATOMA,11740,HCPCS,360,RC,11740,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,450,RC,6230190,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,981,RC,6235070,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE (EG I,11750,HCPCS,360,RC,11750,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,360,RC,11760,CDM,,OUTPATIENT,,,1716,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NAIL BED,11760,HCPCS,450,RC,6230018,CDM,,OUTPATIENT,,,1716,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WEDGE EXCISION SKIN NAIL FOLD,11765,HCPCS,960,RC,11765,CDM,,OUTPATIENT,,,315,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS SIMPLE,11770,HCPCS,360,RC,7212075,CDM,,OUTPATIENT,,,9041,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE,11771,HCPCS,360,RC,7212051,CDM,,OUTPATIENT,,,9041,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL UP TO AND INCLUDING 7 LESIONS,11900,HCPCS,960,RC,11900,CDM,,OUTPATIENT,,,137,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION INTRALESIONAL >7 LESIONS,11901,HCPCS,960,RC,11901,CDM,,OUTPATIENT,,,134,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,11976,HCPCS,360,RC,11976,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERT DRUG DELIVERY IMPLANT,11981,HCPCS,510,RC,11981,CDM,,OUTPATIENT,,,144,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,360,RC,11982,CDM,,OUTPATIENT,,,889,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,981,RC,6230104,CDM,,OUTPATIENT,,,234,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12001,HCPCS,450,RC,120010,CDM,,OUTPATIENT,,,354.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,450,RC,6230031,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,12001,HCPCS,360,RC,12001,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12002,HCPCS,450,RC,5230238,CDM,,OUTPATIENT,,,354.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,12004,HCPCS,450,RC,6230033,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,360,RC,12005,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12005,HCPCS,450,RC,6230034,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE,12006,HCPCS,360,RC,12006,CDM,,OUTPATIENT,,,1059,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,12011,HCPCS,450,RC,6230035,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,981,RC,6230100,CDM,,OUTPATIENT,,,186,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12011,HCPCS,450,RC,6230237,CDM,,OUTPATIENT,,,354.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,450,RC,6230254,CDM,,OUTPATIENT,,,354.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12013,HCPCS,981,RC,6230112,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,12013,HCPCS,450,RC,6230036,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12014,HCPCS,450,RC,6230242,CDM,,OUTPATIENT,,,361.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,450,RC,6230256,CDM,,OUTPATIENT,,,1306,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,360,RC,7212049,CDM,,OUTPATIENT,,,1306,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS,12016,HCPCS,981,RC,6230115,CDM,,OUTPATIENT,,,181,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,12020,HCPCS,450,RC,12020,CDM,,OUTPATIENT,,,1716,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12031,HCPCS,450,RC,6230037,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,12031,HCPCS,360,RC,12031,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,450,RC,6230257,CDM,,OUTPATIENT,,,678.77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12032,HCPCS,981,RC,6230116,CDM,,OUTPATIENT,,,510,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,450,RC,6230038,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,12032,HCPCS,360,RC,12032,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,450,RC,6230039,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12034,HCPCS,360,RC,12034,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12035,HCPCS,360,RC,12035,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR,12036,HCPCS,450,RC,6230040,CDM,,OUTPATIENT,,,1051,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,360,RC,12041,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,12041,HCPCS,761,RC,6230041,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12041,HCPCS,450,RC,120410,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,981,RC,6230108,CDM,,OUTPATIENT,,,426,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,12042,HCPCS,450,RC,6230042,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12042,HCPCS,360,RC,12042,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12044,HCPCS,450,RC,6230043,CDM,,OUTPATIENT,,,1051,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXT,12045,HCPCS,360,RC,12045,CDM,,OUTPATIENT,,,1605,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,360,RC,12051,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE F/E/E/N/L AND/MUC 2.5 CM/<,12051,HCPCS,450,RC,6230044,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,981,RC,6230118,CDM,,OUTPATIENT,,,239,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,6230259,CDM,,OUTPATIENT,,,655.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12051,HCPCS,450,RC,120510,CDM,,OUTPATIENT,,,1132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12052,HCPCS,450,RC,6230258,CDM,,OUTPATIENT,,,655,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACE/EAR/EYE/NOSE/LIP 2.6-5.0 CM 12052,12052,HCPCS,360,RC,6230045,CDM,,OUTPATIENT,,,1119,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12053,HCPCS,450,RC,6230046,CDM,,OUTPATIENT,,,679,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12054 LAYER WOUND REPAIR FACE 7.6 TO 12.5 CM,12054,HCPCS,360,RC,12054,CDM,,OUTPATIENT,,,1059,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INTERMEDIATE WOUNDS OF FACE EARS EYELIDS NOSE L,12055,HCPCS,981,RC,12055,CDM,,OUTPATIENT,,,649,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2,13121,HCPCS,450,RC,6230224,CDM,,OUTPATIENT,,,1050,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX SCALP ARMS AND/OR LEGS EACH ADDITIONAL 5,13122,HCPCS,450,RC,6230225,CDM,,OUTPATIENT,,,231,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,13131,HCPCS,450,RC,6230234,CDM,,OUTPATIENT,,,706,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13131,HCPCS,450,RC,6230244,CDM,,OUTPATIENT,,,746,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,960,RC,13132,CDM,,OUTPATIENT,,,574,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,13132,HCPCS,450,RC,6230233,CDM,,OUTPATIENT,,,1070,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13132,HCPCS,360,RC,7212002,CDM,,OUTPATIENT,,,1605,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,13133,HCPCS,360,RC,7212003,CDM,,OUTPATIENT,,,1070,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR COMPLEX FOREHEAD CHEEKS CHIN MOUTH NECK AXILLA,13133,HCPCS,960,RC,13133,CDM,,OUTPATIENT,,,238,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE,13160,HCPCS,360,RC,13160,CDM,,OUTPATIENT,,,5612,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT SCALP ARMS AND/O,14020,HCPCS,360,RC,14020,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADJACENT TISSUE TRANSFER OR REARRANGEMENT FOREHEAD CHEEKS,14040,HCPCS,360,RC,14040,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPLIT AGRFT T/A/L 1ST 100 CM//1% BDY INFT/CHLD,15100,HCPCS,360,RC,15100,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FULL THICKNESS GRAFT FREE INCLUDING DIRECT CLOSURE OF DONO,15240,HCPCS,360,RC,15240,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT TECH,16000,HCPCS,450,RC,6230193,CDM,,OUTPATIENT,,,344,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN'L TREATMENT 1ST DEGREE BURN LOCAL TREATEMENT PROF,16000,HCPCS,981,RC,6235073,CDM,,OUTPATIENT,,,102,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,981,RC,6235074,CDM,,OUTPATIENT,,,197,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16020,HCPCS,450,RC,160200,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRS AND/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,16020,HCPCS,361,RC,6230122,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,450,RC,6230194,CDM,,OUTPATIENT,,,344,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS INI,16025,HCPCS,981,RC,6230123,CDM,,OUTPATIENT,,,277.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,450,RC,6230195,CDM,,OUTPATIENT,,,269,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRESSIGNS /OR DEBRIDEMENT OF PARTIAL-THICKNESS BURN,16030,HCPCS,981,RC,6235076,CDM,,OUTPATIENT,,,388,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT BENIGN UP TP 14 LESIONS,17000,HCPCS,360,RC,17000,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCT PREMALIG 15 OR MORE LESIONS,17004,HCPCS,360,RC,17004,CDM,,OUTPATIENT,,,1059,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17110 DESTRUCT BENIGN UP TP 14 LESIONS,17110,HCPCS,360,RC,17110,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,450,RC,6230205,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY,17110,HCPCS,750,RC,7210034,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17111 DESTRUCT BENIGN 15 OR MORE LESIONS,17111,HCPCS,360,RC,17111,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,981,RC,6230094,CDM,,OUTPATIENT,,,86.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE PROUD FLES,17250,HCPCS,360,RC,17250,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17260,HCPCS,360,RC,17260,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17261,HCPCS,360,RC,17261,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17262,HCPCS,360,RC,17262,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17263,HCPCS,360,RC,17263,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17264,HCPCS,360,RC,17264,CDM,,OUTPATIENT,,,1059,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17266,HCPCS,360,RC,17266,CDM,,OUTPATIENT,,,1059,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17271,HCPCS,360,RC,17271,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17272,HCPCS,360,RC,17272,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM,17276,HCPCS,360,RC,17276,CDM,,OUTPATIENT,,,1059,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17280,HCPCS,360,RC,17280,CDM,,OUTPATIENT,,,550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
17281 DESTRUCTION MALIGNANT LESION FACE EARS EYELIDS NO,17281,HCPCS,360,RC,17281,CDM,,OUTPATIENT,,,1059,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION MALIGNANT LESION (EG LASER SURGERY ELECTROSUR,17282,HCPCS,360,RC,17282,CDM,,OUTPATIENT,,,1059,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS T,17999,HCPCS,360,RC,17999,CDM,,OUTPATIENT,,,542,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7043010,CDM,,OUTPATIENT,,,402.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505408,CDM,,OUTPATIENT,,,805.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505161,CDM,,OUTPATIENT,,,402.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,960,RC,7505160,CDM,,OUTPATIENT,,,402.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,402,RC,7.04E+13,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19083,HCPCS,761,RC,7043011,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BREAST WITH PLACEMENT OF BREAST LOCALIZATION DEVICE,19084,HCPCS,402,RC,7043009,CDM,,OUTPATIENT,,,1941.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT,19120,HCPCS,360,RC,19120,CDM,,OUTPATIENT,,,9675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY SIMPLE COMPLETE,19303,HCPCS,360,RC,7212024,CDM,,OUTPATIENT,,,17829,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASTECTOMY MODIFIED RADICAL INCLUDING AXILLARY LYMPH NODES,19307,HCPCS,360,RC,19307,CDM,,OUTPATIENT,,,16956,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) EXTRE,20103,HCPCS,360,RC,20103,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY MUSCLE DEEP,20205,HCPCS,360,RC,7212034,CDM,,OUTPATIENT,,,7750,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL (EG ILIUM STE,20220,HCPCS,320,RC,7010668,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,450,RC,8030000,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH SIMPLE,20520,HCPCS,981,RC,8040000,CDM,,OUTPATIENT,,,208,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH DEEP OR,20525,HCPCS,360,RC,7212014,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20526: THERAPEUTIC INJECTION CARPAL TUNNEL,20526,HCPCS,510,RC,20526,CDM,,OUTPATIENT,,,81.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION ENZYME (EG COLLAGENASE) PALMAR FASCIAL CORD (IE,20527,HCPCS,360,RC,20527,CDM,,OUTPATIENT,,,800,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,981,RC,6235034,CDM,,OUTPATIENT,,,480,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE TENDON SHEATH OR LIGAMENT APONEUROSIS,20550,HCPCS,450,RC,6230161,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20550: INJECTION(S) TENDON SHEATH,20550,HCPCS,510,RC,20550,CDM,,OUTPATIENT,,,56.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20551: INJ SINGLE TENDON ORIGIN/INSERTION,20551,HCPCS,510,RC,20551,CDM,,OUTPATIENT,,,56.43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,981,RC,6235035,CDM,,OUTPATIENT,,,84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,450,RC,6230162,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20552: INJ TRIGGER POINTS ONE OR TWO MUSCLES,20552,HCPCS,510,RC,20552,CDM,,OUTPATIENT,,,54.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MU,20552,HCPCS,750,RC,7210056,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20553: INJ TRIGGER POINTS SINGLE/MULTI 3 OR MORE MUSCLES,20553,HCPCS,510,RC,20553,CDM,,OUTPATIENT,,,88.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20600: SMALL JOINT,20600,HCPCS,510,RC,20600,CDM,,OUTPATIENT,,,51.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,450,RC,6230163,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR/INJ SMALL JT/BURSA W/O US,20600,HCPCS,450,RC,6230223,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION SMALL JOINT OR,20600,HCPCS,981,RC,6235036,CDM,,OUTPATIENT,,,480,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,450,RC,206050,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20605: MEDIUM JOINT,20605,HCPCS,510,RC,20605,CDM,,OUTPATIENT,,,53.27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,510,RC,7420001,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION INTERMEDIATE JO,20605,HCPCS,981,RC,6235037,CDM,,OUTPATIENT,,,467,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/US,20606,HCPCS,981,RC,6230219,CDM,,OUTPATIENT,,,126.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20610: LARGE JOINT,20610,HCPCS,510,RC,20610,CDM,,OUTPATIENT,,,64.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505267,CDM,,OUTPATIENT,,,121.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,960,RC,7505268,CDM,,OUTPATIENT,,,121.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ RIGHT,20610,HCPCS,761,RC,7040058,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR JOINT/BURSA MAJOR ARTHR/ASP/INJ LEFT,20610,HCPCS,761,RC,7040057,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,510,RC,7420002,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,981,RC,6235038,CDM,,OUTPATIENT,,,466,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20610,HCPCS,450,RC,6230164,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/O US,20610,HCPCS,450,RC,6230049,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ MAJOR JT/BURSA W/US,20611,HCPCS,361,RC,7043026,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR,20611,HCPCS,960,RC,7505176,CDM,,OUTPATIENT,,,129.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,960,RC,20612,CDM,,OUTPATIENT,,,58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,450,RC,8030001,CDM,,OUTPATIENT,,,952,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION,20612,HCPCS,981,RC,8040001,CDM,,OUTPATIENT,,,58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT SUPERFICIAL (EG BURIED WIRE PIN OR ROD,20670,HCPCS,360,RC,20670,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF IMPLANT DEEP (EG BURIED WIRE PIN SCREW METAL,20680,HCPCS,360,RC,20680,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE) UNILAT,20690,HCPCS,360,RC,20690,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21011,HCPCS,360,RC,21011,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FACE OR SCALP SUBCUTANEOUS,21012,HCPCS,360,RC,21012,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION PROF,21480,HCPCS,981,RC,6235054,CDM,,OUTPATIENT,,,211,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
21480 CLSED TX OF TEMPOROMANDIUBULAR DISLOCATION TECH,21480,HCPCS,450,RC,6230176,CDM,,OUTPATIENT,,,450,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21552,HCPCS,360,RC,21552,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21554,HCPCS,,,7212040,CDM,,OUTPATIENT,,,9041,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/>,21554,HCPCS,960,RC,21554,CDM,,OUTPATIENT,,,1390,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF NECK OR ANTERIOR THORAX SUB,21555,HCPCS,360,RC,21555,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21930,HCPCS,360,RC,21930,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS,21931,HCPCS,360,RC,21931,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBFASCIAL (E,21932,HCPCS,360,RC,21932,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/>,21933,HCPCS,360,RC,21933,CDM,,OUTPATIENT,,,7769,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBFASCIAL (,22901,HCPCS,360,RC,7212025,CDM,,OUTPATIENT,,,7750,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22902,HCPCS,360,RC,22902,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF ABDOMINAL WALL SUBCUTANEOUS,22903,HCPCS,360,RC,22903,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23071,HCPCS,360,RC,23071,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBFASCIAL (E,23073,HCPCS,360,RC,23073,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF SHOULDER AREA SUBCUTANEOUS,23075,HCPCS,360,RC,23075,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAVICULECTOMY PARTIAL,23120,HCPCS,360,RC,23120,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CO,23130,HCPCS,360,RC,23130,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505218,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,233500,CDM,,OUTPATIENT,,,211.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,320,RC,7040008,CDM,,OUTPATIENT,,,211,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT,23350,HCPCS,960,RC,7505217,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23410,HCPCS,360,RC,23410,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF),23412,HCPCS,360,RC,23412,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENODESIS OF LONG TENDON OF BICEPS,23430,HCPCS,360,RC,23430,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AN,23472,HCPCS,360,RC,23472,CDM,,OUTPATIENT,,,37780,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIPULATION,23505,HCPCS,450,RC,6230240,CDM,,OUTPATIENT,,,2869,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CLAVICULAR FRACTURE INCLUDES INTERNAL FIX,23515,HCPCS,360,RC,7212048,CDM,,OUTPATIENT,,,23151,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23600,HCPCS,360,RC,23600,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,360,RC,23605,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL,23605,HCPCS,450,RC,236050,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,23625,HCPCS,960,RC,23625,CDM,,OUTPATIENT,,,667,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,450,RC,236500,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23650,HCPCS,981,RC,6235039,CDM,,OUTPATIENT,,,604,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,360,RC,23655,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,981,RC,6235040,CDM,,OUTPATIENT,,,2725,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANIPULATION,23655,HCPCS,450,RC,236550,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,23655,HCPCS,450,RC,6230207,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,450,RC,6230050,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH FRACTURE OF G,23665,HCPCS,360,RC,23665,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SHOULDER DISLOCATION WITH SURGICAL OR A,23675,HCPCS,360,RC,23675,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION UNDER ANESTHESIA SHOULDER JOINT INCLUDING APP,23700,HCPCS,960,RC,23700,CDM,,OUTPATIENT,,,278.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE UPPER ARM OR ELBOW AREA BURSA,23931,HCPCS,360,RC,23931,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY ELBOW INCLUDING EXPLORATION DRAINAGE OR REMOV,24000,HCPCS,960,RC,24000,CDM,,OUTPATIENT,,,901,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,24075,HCPCS,360,RC,72100057,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OLECRANON BURSA,24105,HCPCS,360,RC,7212068,CDM,,OUTPATIENT,,,10418,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA SUBCUTANEO,24200,HCPCS,360,RC,24200,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY UPPER ARM OR ELBOW AREA DEEP (SUBF,24201,HCPCS,360,RC,24201,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,360,RC,24500,CDM,,OUTPATIENT,,,676,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,360,RC,24505,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,24505,HCPCS,450,RC,6230052,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,981,RC,6230114,CDM,,OUTPATIENT,,,649,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230213,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE WITH MANIPULATIO,24505,HCPCS,450,RC,6230214,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL F,24530,HCPCS,360,RC,24530,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE,24582,HCPCS,360,RC,24582,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,24600,HCPCS,450,RC,6230229,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,360,RC,24600,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,450,RC,6230165,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION WITHOUT ANESTHESIA,24600,HCPCS,981,RC,6235041,CDM,,OUTPATIENT,,,719,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF CLOSED ELBOW DISLOCATION REQUIRING ANESTHESIA,24605,HCPCS,450,RC,6230053,CDM,,OUTPATIENT,,,2838.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,981,RC,6230106,CDM,,OUTPATIENT,,,837,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION A,24620,HCPCS,450,RC,6230248,CDM,,OUTPATIENT,,,5021,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,981,RC,6235043,CDM,,OUTPATIENT,,,181,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,6230251,CDM,,OUTPATIENT,,,725,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD NURSEM,24640,HCPCS,450,RC,246400,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,450,RC,6230166,CDM,,OUTPATIENT,,,2739,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
24655 CLSED TREATMENT OF RADIAL HEAD OR NECK FX W/O MANIPUL,24655,HCPCS,981,RC,6235042,CDM,,OUTPATIENT,,,852,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION EXTENSOR TENDON SHEATH WRIST (EG DE QUERVAINS DI,25000,HCPCS,360,RC,25000,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE FOREARM AND/OR WRIST DEEP ABSCESS OR,25028,HCPCS,360,RC,25028,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25071,HCPCS,360,RC,7212023,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA S,25075,HCPCS,360,RC,25075,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION LESION OF TENDON SHEATH FOREARM AND/OR WRIST,25110,HCPCS,360,RC,25110,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) PRIMARY,25111,HCPCS,360,RC,25111,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF GANGLION WRIST (DORSAL OR VOLAR) RECURRENT,25112,HCPCS,360,RC,25112,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY FOREARM OR WR,25248,HCPCS,360,RC,25248,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON OR MUSCLE EXTENSOR FOREARM AND/OR WRIST PR,25270,HCPCS,360,RC,7212053,CDM,,OUTPATIENT,,,10418,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF NONUNION OR MALUNION RADIUS OR ULNA WITH AUTOGRA,25405,HCPCS,360,RC,25405,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY INTERPOSITION INTERCARPAL OR CARPOMETACARPAL,25447,HCPCS,360,RC,25447,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE WITH MANIPULATION,25505,HCPCS,450,RC,25505,CDM,,OUTPATIENT,,,2781,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,25530,HCPCS,960,RC,25530,CDM,,OUTPATIENT,,,502,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITHOU,25560,HCPCS,450,RC,25560,CDM,,OUTPATIENT,,,459,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX RADIAL ANDULNAR SHAFT FRACTURES W/MANJ,25565,HCPCS,450,RC,6230054,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,360,RC,25565,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH M,25565,HCPCS,450,RC,255650,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES WITH INT,25575,HCPCS,360,RC,25575,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25600,HCPCS,360,RC,25600,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,25605,HCPCS,450,RC,6230055,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,360,RC,25605,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,450,RC,6230255,CDM,,OUTPATIENT,,,2821.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG COLLES OR SM,25605,HCPCS,981,RC,6230113,CDM,,OUTPATIENT,,,1067,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR,25606,HCPCS,360,RC,25606,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,25607,HCPCS,360,RC,25607,CDM,,OUTPATIENT,,,20522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,25609,HCPCS,360,RC,25609,CDM,,OUTPATIENT,,,20522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE WI,25622,HCPCS,960,RC,25622,CDM,,OUTPATIENT,,,410,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL S,25630,HCPCS,360,RC,25630,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,25652,HCPCS,360,RC,25652,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF FINGER ABSCESS SIMPLE,26010,HCPCS,360,RC,26010,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF TENDON SHEATH DIGIT AND/OR PALM EACH,26020,HCPCS,360,RC,26020,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENDON SHEATH INCISION (EG FOR TRIGGER FINGER),26055,HCPCS,360,RC,26055,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,26060,HCPCS,360,RC,26060,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY WITH EXPLORATION DRAINAGE OR REMOVAL OF LOOSE,26080,HCPCS,360,RC,7212009,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26111,HCPCS,360,RC,26111,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR OR VASCULAR MALFORMATION SOFT TISSUE OF HAN,26115,HCPCS,360,RC,26115,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FASCIECTOMY PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INC,26123,HCPCS,360,RC,26123,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG CY,26160,HCPCS,360,RC,26160,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION/CURETTAGE CYST/TUMOR METACARPAL,26200,HCPCS,360,RC,7212005,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACA,26200,HCPCS,960,RC,26200,CDM,,OUTPATIENT,,,855,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,26236,HCPCS,360,RC,26236,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION FINGER JOINT UNDER ANESTHESIA EACH JOINT,26340,HCPCS,360,RC,26340,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANIPULATION PALMAR FASCIAL CORD (IE DUPUYTREN'S CORD) PO,26341,HCPCS,360,RC,26341,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OR ADVANCEMENT FLEXOR TENDON NOT IN ZONE 2 DIGITAL,26350,HCPCS,360,RC,26350,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,360,RC,26418,CDM,,OUTPATIENT,,,5652,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR EXTENSOR TENDON FINGER PRIMARY OR SECONDARY WITHO,26418,HCPCS,450,RC,6230200,CDM,,OUTPATIENT,,,5652,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REALIGNMENT OF EXTENSOR TENDON HAND EACH TENDON,26437,HCPCS,360,RC,26437,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY FLEXOR FINGER OPEN EACH TENDON,26455,HCPCS,360,RC,26455,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITHOUT MAN,26600,HCPCS,360,RC,26600,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METACARPAL FRACTURE SINGLE WITH MANIPU,26605,HCPCS,360,RC,26605,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE EACH,26608,HCPCS,360,RC,26608,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION THUM,26665,HCPCS,360,RC,26665,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26720,HCPCS,960,RC,26720,CDM,,OUTPATIENT,,,272,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,360,RC,26725,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE PROXIMAL OR M,26725,HCPCS,450,RC,6230058,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING METACARPOP,26742,HCPCS,450,RC,6230247,CDM,,OUTPATIENT,,,5021,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26750,HCPCS,360,RC,26750,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FINGER OR TH,26755,HCPCS,450,RC,6230243,CDM,,OUTPATIENT,,,414,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,981,RC,6235044,CDM,,OUTPATIENT,,,549,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX IPHAL JT DISLC W/MANJ W/O ANES,26770,HCPCS,450,RC,267700,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION SINGL,26770,HCPCS,450,RC,6230167,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISL,26776,HCPCS,360,RC,26776,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS INTERPHALANGEAL JOINT WITH OR WITHOUT INTERNAL,26860,HCPCS,360,RC,26860,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION FINGER OR THUMB PRIMARY OR SECONDARY ANY JOINT,26951,HCPCS,360,RC,26951,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID PELVIS/HIP JOINT AREA INFECTED BURSA,26991,HCPCS,960,RC,26991,CDM,,OUTPATIENT,,,995,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF PELVIS AND HIP AREA SUBCUTA,27043,HCPCS,360,RC,27043,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505386,CDM,,OUTPATIENT,,,173.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY WITHOUT ANESTHESIA,27093,HCPCS,972,RC,7505385,CDM,,OUTPATIENT,,,173.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP RIGHT,27093,HCPCS,320,RC,7040122,CDM,,OUTPATIENT,,,279.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM INJECTION HIP LEFT,27093,HCPCS,320,RC,7040121,CDM,,OUTPATIENT,,,279.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096-50 BILATERAL SACROILIAC JOINT INJECTION,27096,HCPCS,960,RC,2709650,CDM,,OUTPATIENT,,,337.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27096 INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/S,27096,HCPCS,761,RC,27096,CDM,,OUTPATIENT,,,1933,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMIARTHROPLASTY HIP PARTIAL (EG FEMORAL STEM PROSTHESIS,27125,HCPCS,960,RC,27125,CDM,,OUTPATIENT,,,2772.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REP,27130,HCPCS,360,RC,27130,CDM,,OUTPATIENT,,,37780,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END NECK INTE,27236,HCPCS,960,RC,27236,CDM,,OUTPATIENT,,,2927.26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27244,HCPCS,960,RC,27244,CDM,,OUTPATIENT,,,3009.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INTERTROCHANTERIC PERITROCHANTERIC OR SUBTROC,27245,HCPCS,960,RC,27245,CDM,,OUTPATIENT,,,3010.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES TECH,27250,HCPCS,450,RC,6230168,CDM,,OUTPATIENT,,,450,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
27250 CLSOED TREATEMENT OF HIP DISLOCATION W/O ANES PROF,27250,HCPCS,981,RC,6235045,CDM,,OUTPATIENT,,,789,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF HIP DISLOCATION TRAUMATIC REQUIRING AN,27252,HCPCS,360,RC,27252,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,981,RC,272651,CDM,,OUTPATIENT,,,590.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,450,RC,272650,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION WITHO,27265,HCPCS,360,RC,27265,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,450,RC,272661,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION REQUI,27266,HCPCS,360,RC,27266,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE PROXIMAL END HEAD INCL,27269,HCPCS,960,RC,27269,CDM,,OUTPATIENT,,,2679.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE DEEP ABSCESS BURSA OR HEMATOMA THI,27301,HCPCS,360,RC,27301,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27327,HCPCS,360,RC,27327,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB,27331,HCPCS,960,RC,27331,CDM,,OUTPATIENT,,,307,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF THIGH OR KNEE AREA SUBCUTAN,27337,HCPCS,360,RC,27337,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION PREPATELLAR BURSA,27340,HCPCS,360,RC,27340,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE INFRAPATELLAR TENDON PRIMARY,27380,HCPCS,960,RC,27380,CDM,,OUTPATIENT,,,1180,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE PRIMARY,27385,HCPCS,360,RC,7212033,CDM,,OUTPATIENT,,,19844,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL C,27446,HCPCS,360,RC,27446,CDM,,OUTPATIENT,,,37780,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL,27447,HCPCS,360,RC,27447,CDM,,OUTPATIENT,,,37780,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPARTMENT (,27496,HCPCS,360,RC,7212012,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,981,RC,6230119,CDM,,OUTPATIENT,,,1072,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITH MANIPULATIO,27502,HCPCS,450,RC,6230260,CDM,,OUTPATIENT,,,5021,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN,27511,HCPCS,960,RC,27511,CDM,,OUTPATIENT,,,1891,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FEMORAL FRACTURE DISTAL END MEDIAL OR LA,27514,HCPCS,960,RC,27514,CDM,,OUTPATIENT,,,2295.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF PATELLAR FRACTURE WITH INTERNAL FIXATION,27524,HCPCS,360,RC,7212036,CDM,,OUTPATIENT,,,19844,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL (PLATEAU) WIT,27530,HCPCS,,,27530,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF KNEE DISLOCATION REQUIRING ANESTHESIA,27552,HCPCS,450,RC,275520,CDM,,OUTPATIENT,,,1236,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,981,RC,6230208,CDM,,OUTPATIENT,,,694,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PATELLAR DISLOCATION WITHOUT ANESTHESIA,27560,HCPCS,450,RC,6230061,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION THIGH THROUGH FEMUR ANY LEVEL,27590,HCPCS,960,RC,27590,CDM,,OUTPATIENT,,,1382.26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE LEG OR ANKLE DEEP ABSCESS OR HEMATOM,27603,HCPCS,360,RC,7212065,CDM,,OUTPATIENT,,,9041,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF LEG OR ANKLE AREA SUBCUTANE,27618,HCPCS,360,RC,27618,CDM,,OUTPATIENT,,,4311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG CYST OR,27630,HCPCS,360,RC,7212030,CDM,,OUTPATIENT,,,8929.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSEC,27641,HCPCS,360,RC,27641,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON,27650,HCPCS,360,RC,27650,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT F,27750,HCPCS,360,RC,27750,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,27752,HCPCS,450,RC,6230235,CDM,,OUTPATIENT,,,2845,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITHOUT MANIP,27760,HCPCS,960,RC,27760,CDM,,OUTPATIENT,,,294.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE WITH MANIPULA,27762,HCPCS,360,RC,27762,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE INCLUDES INTERN,27766,HCPCS,360,RC,27766,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE WITHO,27780,HCPCS,450,RC,6230241,CDM,,OUTPATIENT,,,414.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,450,RC,6230127,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOL,27786,HCPCS,360,RC,27786,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS,27792,HCPCS,360,RC,27792,CDM,,OUTPATIENT,,,20522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,360,RC,27808,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230062,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,981,RC,6235049,CDM,,OUTPATIENT,,,644,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL,27808,HCPCS,450,RC,6230171,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,27810,HCPCS,450,RC,6230063,CDM,,OUTPATIENT,,,4564,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG LATERAL AN,27814,HCPCS,360,RC,27814,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WITH MANIPU,27818,HCPCS,450,RC,27818,CDM,,OUTPATIENT,,,2821,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27822,HCPCS,360,RC,27822,CDM,,OUTPATIENT,,,20522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE INCLUDES INTE,27823,HCPCS,360,RC,27823,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27827,HCPCS,360,RC,27827,CDM,,OUTPATIENT,,,37780,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFA,27828,HCPCS,360,RC,27828,CDM,,OUTPATIENT,,,37780,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DI,27829,HCPCS,360,RC,7212039,CDM,,OUTPATIENT,,,23151,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,450,RC,6230064,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION WITHOUT ANESTHESIA,27840,HCPCS,360,RC,27840,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA,27842,HCPCS,360,RC,27842,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TENOTOMY PERCUTANEOUS TOE SINGLE TENDON,28010,HCPCS,360,RC,28010,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF L,28024,HCPCS,360,RC,28024,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION TUMOR SOFT TISSUE OF FOOT OR TOE SUBCUTANEOUS 1,28039,HCPCS,360,RC,28039,CDM,,OUTPATIENT,,,7265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION TENDON TENDON SHEATH OR CAPSULE (INCLU,28092,HCPCS,360,RC,7212055,CDM,,OUTPATIENT,,,5021,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR TARSAL O,28104,HCPCS,360,RC,28104,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONET,28110,HCPCS,360,RC,28110,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTECTOMY CALCANEUS,28118,HCPCS,360,RC,7211058,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS,28190,HCPCS,360,RC,28190,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR TENDON EXTENSOR FOOT PRIMARY OR SECONDARY EACH T,28208,HCPCS,360,RC,7212008,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HAMMERTOE (EG INTERPHALANGEAL FUSION PARTIAL O,28285,HCPCS,360,RC,28285,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND,28289,HCPCS,360,RC,28289,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28295,HCPCS,960,RC,28295,CDM,,OUTPATIENT,,,1152.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORRECTION HALLUX VALGUS (BUNIONECTOMY) WITH SESAMOIDECTOM,28296,HCPCS,360,RC,28296,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCED,28313,HCPCS,360,RC,28313,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BO,28322,HCPCS,360,RC,28322,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF CALCANEAL FRACTURE WITH MANIPULATION,28405,HCPCS,360,RC,28405,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF METATARSAL FRACTURE WITHOUT MANIPULATIO,28470,HCPCS,360,RC,28470,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE WITH,28476,HCPCS,360,RC,28476,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28490,HCPCS,960,RC,28490,CDM,,OUTPATIENT,,,178,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPEN TREATMENT OF FRACTURE GREAT TOE PHALANX OR PHALANGES,28505,HCPCS,360,RC,7212045,CDM,,OUTPATIENT,,,10418,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28510,HCPCS,960,RC,28510,CDM,,OUTPATIENT,,,172,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF FRACTURE PHALANX OR PHALANGES OTHER TH,28515,HCPCS,360,RC,28515,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSED TREATMENT OF SESAMOID FRACTURE,28530,HCPCS,960,RC,28530,CDM,,OUTPATIENT,,,144,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,28660,HCPCS,450,RC,28660,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT,28750,HCPCS,360,RC,28750,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION METATARSAL WITH TOE SINGLE,28810,HCPCS,360,RC,7212066,CDM,,OUTPATIENT,,,10418,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPUTATION TOE INTERPHALANGEAL JOINT,28825,HCPCS,360,RC,28825,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PROCEDURE FOOT OR TOES,28899,HCPCS,360,RC,28899,CDM,,OUTPATIENT,,,632,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST SHOULDER TO HAND (LONG ARM),29065,HCPCS,360,RC,29065,CDM,,OUTPATIENT,,,739,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST ELBOW TO FINGER (SHORT ARM),29075,HCPCS,360,RC,29075,CDM,,OUTPATIENT,,,739,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION CAST HAND AND LOWER FOREARM (GAUNTLET),29085,HCPCS,360,RC,29085,CDM,,OUTPATIENT,,,433,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,291050,CDM,,OUTPATIENT,,,463,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6230099,CDM,,OUTPATIENT,,,463,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),29105,HCPCS,450,RC,6235046,CDM,,OUTPATIENT,,,463,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230065,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,360,RC,29125,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,981,RC,6235047,CDM,,OUTPATIENT,,,196,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) STATIC,29125,HCPCS,450,RC,6230169,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,360,RC,29130,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230226,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,450,RC,6230170,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF FINGER SPLINT STATIC,29130,HCPCS,981,RC,6235048,CDM,,OUTPATIENT,,,197,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER TECH,29240,HCPCS,450,RC,6230172,CDM,,OUTPATIENT,,,154,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29240 STRAPPING SHOULDER PROF,29240,HCPCS,981,RC,6235050,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,960,RC,7042106,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING HAND OR FINGER,29280,HCPCS,981,RC,6230091,CDM,,OUTPATIENT,,,50,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG CAST BRACE,29358,HCPCS,960,RC,29358,CDM,,OUTPATIENT,,,144.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,360,RC,29405,CDM,,OUTPATIENT,,,790,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,981,RC,6235055,CDM,,OUTPATIENT,,,133,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),29405,HCPCS,450,RC,6230177,CDM,,OUTPATIENT,,,790,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) WALKING,29425,HCPCS,360,RC,29425,CDM,,OUTPATIENT,,,739,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,29505,CDM,,OUTPATIENT,,,463,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,981,RC,6235051,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),29505,HCPCS,450,RC,6230173,CDM,,OUTPATIENT,,,463,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,360,RC,29515,CDM,,OUTPATIENT,,,463,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230101,CDM,,OUTPATIENT,,,200,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,450,RC,6230174,CDM,,OUTPATIENT,,,463,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION SHORT LEG SPLINT CALF FOOT,29515,HCPCS,450,RC,6230231,CDM,,OUTPATIENT,,,463,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),29515,HCPCS,981,RC,6235052,CDM,,OUTPATIENT,,,197,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT PROF,29540,HCPCS,981,RC,6235053,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
29540 STRAPPING ANKLE/FOOT TECH,29540,HCPCS,450,RC,6230175,CDM,,OUTPATIENT,,,282,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230066,CDM,,OUTPATIENT,,,182,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,981,RC,6230109,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING TOES,29550,HCPCS,450,RC,6230250,CDM,,OUTPATIENT,,,125.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAPPING UNNA BOOT,29580,HCPCS,420,RC,7080030,CDM,,OUTPATIENT,,,290.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY,29806,HCPCS,360,RC,29806,CDM,,OUTPATIENT,,,20522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION,29807,HCPCS,360,RC,29807,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR,29822,HCPCS,360,RC,29822,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 O,29823,HCPCS,360,RC,29823,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLU,29824,HCPCS,360,RC,29824,CDM,,OUTPATIENT,,,9279,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF,29825,HCPCS,360,RC,29825,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIA,29826,HCPCS,960,RC,29826,CDM,,OUTPATIENT,,,238,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR,29827,HCPCS,360,RC,29827,CDM,,OUTPATIENT,,,20522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS,29828,HCPCS,360,RC,29828,CDM,,OUTPATIENT,,,20522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPY WRIST SURGICAL WITH RELEASE OF TRANSVERSE CARPA,29848,HCPCS,360,RC,29848,CDM,,OUTPATIENT,,,4268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE PROXIMA,29855,HCPCS,360,RC,29855,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE INFECTION LAVAGE DRAINAGE,29871,HCPCS,360,RC,29871,CDM,,OUTPATIENT,,,9279,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE BODY OR FO,29874,HCPCS,360,RC,29874,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE C,29876,HCPCS,360,RC,7212070,CDM,,OUTPATIENT,,,10418,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,29877,HCPCS,360,RC,29877,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES,29879,HCPCS,360,RC,29879,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL,29880,HCPCS,360,RC,29880,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG,29881,HCPCS,360,RC,29881,CDM,,OUTPATIENT,,,9279,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR,29882,HCPCS,360,RC,29882,CDM,,OUTPATIENT,,,9279,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AN,29883,HCPCS,360,RC,7212007,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUG,29888,HCPCS,360,RC,29888,CDM,,OUTPATIENT,,,19191,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC PLANTAR FASCIOTOMY,29893,HCPCS,360,RC,29893,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURG,29897,HCPCS,360,RC,29897,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE,29898,HCPCS,360,RC,29898,CDM,,OUTPATIENT,,,8677,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,450,RC,6230102,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY INTRANASAL OFFICE TYPE PROCEDURE,30300,HCPCS,981,RC,6235057,CDM,,OUTPATIENT,,,367,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,360,RC,30901,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230068,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,450,RC,6230179,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE (LIMITED CAUTERY,30901,HCPCS,981,RC,6235058,CDM,,OUTPATIENT,,,198,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,450,RC,6230103,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX (EXTENSIVE CAUTE,30903,HCPCS,981,RC,6235059,CDM,,OUTPATIENT,,,172,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,450,RC,6230261,CDM,,OUTPATIENT,,,406,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTROL NASAL HEMORRHAGE POSTERIOR WITH POSTERIOR NASAL PA,30905,HCPCS,981,RC,6235060,CDM,,OUTPATIENT,,,145.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,450,RC,6230180,CDM,,OUTPATIENT,,,399,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30906 CONTROL NASAL HEMORRHAGE POSTERIAL W/NASAL PACKS SUB,30906,HCPCS,981,RC,6235061,CDM,,OUTPATIENT,,,300,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,361,RC,65012,CDM,,OUTPATIENT,,,693,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,981,RC,6230105,CDM,,OUTPATIENT,,,438.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,31500,HCPCS,360,RC,31500,CDM,,OUTPATIENT,,,693,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE PROF,31575,HCPCS,981,RC,6235028,CDM,,OUTPATIENT,,,277,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31575 LARYNGOSCOPY FLEXIBLE TECH,31575,HCPCS,450,RC,6230154,CDM,,OUTPATIENT,,,364,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS PROF,31601,HCPCS,981,RC,6235005,CDM,,OUTPATIENT,,,4629,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31601 TRACEOSTOMY YOUNGER THAN 2 YRS TECH,31601,HCPCS,450,RC,6230130,CDM,,OUTPATIENT,,,9295,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL PROF,31603,HCPCS,981,RC,6235006,CDM,,OUTPATIENT,,,1429,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TECH,31603,HCPCS,450,RC,6230132,CDM,,OUTPATIENT,,,2268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,981,RC,6235007,CDM,,OUTPATIENT,,,1429,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,31605,HCPCS,450,RC,6230131,CDM,,OUTPATIENT,,,1302.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE PROF,31610,HCPCS,981,RC,6235008,CDM,,OUTPATIENT,,,1545,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31610 TRACHEOSTOMY FENESTRATION PROCEDURE TECH,31610,HCPCS,450,RC,6230133,CDM,,OUTPATIENT,,,679,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE PROF,31612,HCPCS,981,RC,6235009,CDM,,OUTPATIENT,,,8301,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
31612 TRACHEAL PUNCTURE TECH,31612,HCPCS,450,RC,6230134,CDM,,OUTPATIENT,,,8301,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHOSCOPY RIGID OR FLEXIBLE INCLUDING FLUOROSCOPIC GUID,31622,HCPCS,360,RC,31622,CDM,,OUTPATIENT,,,4584,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,350,RC,7042013,CDM,,OUTPATIENT,,,3034.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORE NEEDLE BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS INCLU,32408,HCPCS,960,RC,7505015,CDM,,OUTPATIENT,,,255.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,960,RC,7505070,CDM,,OUTPATIENT,,,337.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,360,RC,32551,CDM,,OUTPATIENT,,,4607,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230137,CDM,,OUTPATIENT,,,4607,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM (E,32551,HCPCS,981,RC,6235011,CDM,,OUTPATIENT,,,1004,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACOSTOMY W/ DRAINAGE,32551,HCPCS,361,RC,7042070,CDM,,OUTPATIENT,,,4607,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBE THORACOSTOMY INCLUDES WATER SEAL,32551,HCPCS,450,RC,6230228,CDM,,OUTPATIENT,,,4607,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,360,RC,32554,CDM,,OUTPATIENT,,,1771,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,,,6230070,CDM,,OUTPATIENT,,,1586.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32554,HCPCS,450,RC,6230135,CDM,,OUTPATIENT,,,1771,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE OR CATHETER ASPIRATION OF THE PLEURAL,32555,HCPCS,402,RC,7040200,CDM,,OUTPATIENT,,,3079.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,32555,HCPCS,360,RC,32555,CDM,,OUTPATIENT,,,1771,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,450,RC,6230136,CDM,,OUTPATIENT,,,3213.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLEURAL DRAINAGE PERCUTANEOUS WITH INSERTION OF INDWELLING,32556,HCPCS,981,RC,6235010,CDM,,OUTPATIENT,,,261,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,33016,HCPCS,450,RC,6230239,CDM,,OUTPATIENT,,,2872,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,450,RC,6230139,CDM,,OUTPATIENT,,,26731,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,360,RC,33210,CDM,,OUTPATIENT,,,26731,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHA,33210,HCPCS,981,RC,6235013,CDM,,OUTPATIENT,,,9421,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEM,33228,HCPCS,360,RC,33228,CDM,,OUTPATIENT,,,31858,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,35206,HCPCS,360,RC,35206,CDM,,OUTPATIENT,,,8771,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN PROF,36000,HCPCS,981,RC,6235014,CDM,,OUTPATIENT,,,62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36000 INDO OF NEEDLE INTO VEIN TECH,36000,HCPCS,450,RC,6230140,CDM,,OUTPATIENT,,,71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS PROF,36400,HCPCS,981,RC,6235015,CDM,,OUTPATIENT,,,71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36400 VENIPUNCTURE YOUNGER THAN 3 YRS TECH,36400,HCPCS,450,RC,6230141,CDM,,OUTPATIENT,,,71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN TECH,36405,HCPCS,450,RC,6230142,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36405 VENIPUNCTURE SCALP VEIN PROF,36405,HCPCS,981,RC,6235016,CDM,,OUTPATIENT,,,99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,361,RC,65108,CDM,,OUTPATIENT,,,83.43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,981,RC,6235017,CDM,,OUTPATIENT,,,208,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE YOUNGER THAN AGE 3 YEARS NECESSITATING THE SK,36406,HCPCS,450,RC,6230143,CDM,,OUTPATIENT,,,83,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,450,RC,6230144,CDM,,OUTPATIENT,,,83,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,361,RC,65106,CDM,,OUTPATIENT,,,83.43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE AGE 3 YEARS OR OLDER NECESSITATING THE SKILL,36410,HCPCS,981,RC,6235018,CDM,,OUTPATIENT,,,114,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENIPUNCTURE-CHARGE ONLY,36415,HCPCS,300,RC,35200,CDM,,OUTPATIENT,,,11.33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,7010658,CDM,,OUTPATIENT,,,11.33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,HCPCS,391,RC,6020001,CDM,,OUTPATIENT,,,641.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS PROF,36555,HCPCS,981,RC,6235019,CDM,,OUTPATIENT,,,2053,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
36555 INSERT CENTRAL VENOUS CATH < 5YRS TECH,36555,HCPCS,450,RC,6230145,CDM,,OUTPATIENT,,,1991,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,360,RC,36556,CDM,,OUTPATIENT,,,9379,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,361,RC,65037,CDM,,OUTPATIENT,,,9379,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230146,CDM,,OUTPATIENT,,,9379,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,450,RC,6230072,CDM,,OUTPATIENT,,,9379,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS,36556,HCPCS,981,RC,6235020,CDM,,OUTPATIENT,,,1993,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATH,36558,HCPCS,360,RC,36558,CDM,,OUTPATIENT,,,8771,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCE,36561,HCPCS,360,RC,36561,CDM,,OUTPATIENT,,,8771,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/O IMG GDN 5 YR/>,36569,HCPCS,761,RC,65038,CDM,,OUTPATIENT,,,4607,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION PICC W/RS ANDI 5 YR/>,36573,HCPCS,230,RC,36573,CDM,,OUTPATIENT,,,893,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER WITHOUT SUBCUTA,36589,HCPCS,360,RC,36589,CDM,,OUTPATIENT,,,1771,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE WITH SUBCU,36590,HCPCS,360,RC,36590,CDM,,OUTPATIENT,,,4308,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,450,RC,6230196,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,36591,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE V,36591,HCPCS,361,RC,7200001,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,450,RC,6230197,CDM,,OUTPATIENT,,,225,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PE,36592,HCPCS,300,RC,7200002,CDM,,OUTPATIENT,,,225,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,7200003,CDM,,OUTPATIENT,,,436.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCES,36593,HCPCS,761,RC,36593,CDM,,OUTPATIENT,,,436.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER U,36597,HCPCS,360,RC,36597,CDM,,OUTPATIENT,,,4308,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,972,RC,7505387,CDM,,OUTPATIENT,,,89.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING,36598,HCPCS,761,RC,365980,CDM,,OUTPATIENT,,,424.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,36600,HCPCS,300,RC,7010659,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230147,CDM,,OUTPATIENT,,,109,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,450,RC,6230221,CDM,,OUTPATIENT,,,109,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING MONITO,36620,HCPCS,361,RC,366201,CDM,,OUTPATIENT,,,109.18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION,36680,HCPCS,450,RC,6230074,CDM,,OUTPATIENT,,,611,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR BIOPSY TEMPORAL ARTERY,37609,HCPCS,360,RC,37609,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW ASPIRATION(S),38220,HCPCS,360,RC,38220,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES),38221,HCPCS,360,RC,38221,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,360,RC,38222,CDM,,OUTPATIENT,,,7769,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC BONE MARROW BIOPSY(IES) AND ASPIRATION(S),38222,HCPCS,761,RC,7046170,CDM,,OUTPATIENT,,,7769,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL,38500,HCPCS,360,RC,38500,CDM,,OUTPATIENT,,,9675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) BY NEEDLE SUPERFICIAL,38505,HCPCS,320,RC,7040202,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP CERVICAL NOD,38510,HCPCS,360,RC,38510,CDM,,OUTPATIENT,,,9675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN DEEP AXILLARY NOD,38525,HCPCS,360,RC,38525,CDM,,OUTPATIENT,,,9675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7211060,CDM,,OUTPATIENT,,,9675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN INGUINOFEMORAL NO,38531,HCPCS,360,RC,7212041,CDM,,OUTPATIENT,,,12032,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIP,40490,HCPCS,960,RC,40490,CDM,,OUTPATIENT,,,177.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA TECH,40650,HCPCS,450,RC,6230191,CDM,,OUTPATIENT,,,996,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA VESTIBULE OF MOUTH SIM,40800,HCPCS,360,RC,40800,CDM,,OUTPATIENT,,,1907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,981,RC,6235004,CDM,,OUTPATIENT,,,337.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF EMBEDDED FOREIGN BODY VESTIBULE OF MOUTH SIMPLE,40804,HCPCS,450,RC,6230128,CDM,,OUTPATIENT,,,1576.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY VESTIBULE OF MOUTH,40808,HCPCS,360,RC,40808,CDM,,OUTPATIENT,,,1386,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40810,HCPCS,360,RC,40810,CDM,,OUTPATIENT,,,8382,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOU,40812,HCPCS,360,RC,40812,CDM,,OUTPATIENT,,,4145,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF FRENUM LABIAL OR BUCCAL (FRENUMECTOMY FRENULEC,40819,HCPCS,360,RC,40819,CDM,,OUTPATIENT,,,4145,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION LINGUAL FRENUM FRENOTOMY,41010,HCPCS,360,RC,41010,CDM,,OUTPATIENT,,,4145,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,960,RC,41112,CDM,,OUTPATIENT,,,474.83,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION OF TONGUE WITH CLOSURE ANTERIOR TWO-THIR,41112,HCPCS,360,RC,7212050,CDM,,OUTPATIENT,,,9958,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF LACERATION OF TONGUE FLOOR OF MOUTH OVER 2,41252,HCPCS,450,RC,6230230,CDM,,OUTPATIENT,,,432,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,450,RC,6230252,CDM,,OUTPATIENT,,,406,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,41800,HCPCS,450,RC,41800,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF ABSCESS CYST HEMATOMA FROM DENTOALVEOLAR STRUC,41800,HCPCS,981,RC,6230110,CDM,,OUTPATIENT,,,216,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE ABSCESS PERITONSILLAR,42700,HCPCS,450,RC,6230075,CDM,,OUTPATIENT,,,484,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY FROM PHARYNX,42809,HCPCS,450,RC,42809,CDM,,OUTPATIENT,,,700,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING CO,43200,HCPCS,360,RC,43200,CDM,,OUTPATIENT,,,2479,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,750,RC,7210040,CDM,,OUTPATIENT,,,5322,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR M,43202,HCPCS,360,RC,43202,CDM,,OUTPATIENT,,,5322,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,360,RC,43220,CDM,,OUTPATIENT,,,5322,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH TRANSENDOSCOPIC BAL,43220,HCPCS,750,RC,7210041,CDM,,OUTPATIENT,,,5322,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,960,RC,43235,CDM,,OUTPATIENT,,,365.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC,43235,HCPCS,750,RC,7210000,CDM,,OUTPATIENT,,,2651,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43236,HCPCS,960,RC,43236,CDM,,OUTPATIENT,,,447.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION,43236,HCPCS,750,RC,7210007,CDM,,OUTPATIENT,,,2651,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE,43239,HCPCS,750,RC,7210001,CDM,,OUTPATIENT,,,2651,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY,43239,HCPCS,960,RC,43239,CDM,,OUTPATIENT,,,434.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATI,43245,HCPCS,750,RC,7210008,CDM,,OUTPATIENT,,,2062.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,960,RC,43246,CDM,,OUTPATIENT,,,639.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECT,43246,HCPCS,750,RC,7210005,CDM,,OUTPATIENT,,,949.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,750,RC,7210002,CDM,,OUTPATIENT,,,1622.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43247,HCPCS,960,RC,43247,CDM,,OUTPATIENT,,,508.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM,43249,HCPCS,750,RC,7210006,CDM,,OUTPATIENT,,,5322,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH TRANSE,43249,HCPCS,960,RC,43249,CDM,,OUTPATIENT,,,432.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43250,HCPCS,750,RC,7210004,CDM,,OUTPATIENT,,,949.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,960,RC,43251,CDM,,OUTPATIENT,,,554.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVA,43251,HCPCS,750,RC,7210003,CDM,,OUTPATIENT,,,949.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ENDOSC,43254,HCPCS,750,RC,7212029,CDM,,OUTPATIENT,,,5225,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,750,RC,7210009,CDM,,OUTPATIENT,,,3093.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH CONTRO,43255,HCPCS,960,RC,43255,CDM,,OUTPATIENT,,,700.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,,,43257,CDM,,OUTPATIENT,,,9408,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DELIVE,43257,HCPCS,750,RC,7210042,CDM,,OUTPATIENT,,,5992.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH ABLATI,43270,HCPCS,750,RC,7210043,CDM,,OUTPATIENT,,,3093.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION OF ESOPHAGUS BY UNGUIDED SOUND OR BOUGIE SINGLE O,43450,HCPCS,750,RC,7210038,CDM,,OUTPATIENT,,,1622.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO/ORO-GASTRIC TUBE PLMT REQ PHYSFLUOR GDNCE,43752,HCPCS,450,RC,6230222,CDM,,OUTPATIENT,,,889,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,981,RC,6235024,CDM,,OUTPATIENT,,,218,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,450,RC,6230151,CDM,,OUTPATIENT,,,889,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NASO- OR ORO-GASTRIC TUBE PLACEMENT REQUIRING PHYSICIAN'S S,43752,HCPCS,360,RC,43752,CDM,,OUTPATIENT,,,889,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,981,RC,6235025,CDM,,OUTPATIENT,,,77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,360,RC,43762,CDM,,OUTPATIENT,,,872,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230020,CDM,,OUTPATIENT,,,872,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPLACEMENT OF GASTROSTOMY TUBE PERCUTANEOUS INCLUDES REMO,43762,HCPCS,450,RC,6230152,CDM,,OUTPATIENT,,,872,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRORRHAPHY SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCE,43840,HCPCS,960,RC,43840,CDM,,OUTPATIENT,,,3216.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTEROLSS FRING INTSTINAL ADHESION SPX,44005,HCPCS,360,RC,7212020,CDM,,OUTPATIENT,,,3569.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL,44025,HCPCS,960,RC,44025,CDM,,OUTPATIENT,,,1871,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOTOMY FOR EXPLORATION BIOPSY(S) OR FOREIGN BODY REMOVA,44025,HCPCS,360,RC,7212000,CDM,,OUTPATIENT,,,2479,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT,44050,HCPCS,360,RC,7212019,CDM,,OUTPATIENT,,,2479.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF 1 OR MORE LESIONS OF SMALL OR LARGE INTESTINE NO,44110,HCPCS,960,RC,44110,CDM,,OUTPATIENT,,,1753.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST,44120,HCPCS,960,RC,44120,CDM,,OUTPATIENT,,,2986,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH ANASTOMOSIS,44140,HCPCS,960,RC,44140,CDM,,OUTPATIENT,,,3277.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY PARTIAL WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY,44141,HCPCS,960,RC,44141,CDM,,OUTPATIENT,,,4471.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLECTOMY TOTAL ABDOMINAL WITHOUT PROCTECTOMY WITH ILEOS,44150,HCPCS,761,RC,44150,CDM,,OUTPATIENT,,,592,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL ENTEROLYSIS (FREEING OF INTESTINAL AD,44180,HCPCS,360,RC,44180,CDM,,OUTPATIENT,,,15503,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS,44204,HCPCS,360,RC,44204,CDM,,OUTPATIENT,,,10335,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL COLECTOMY PARTIAL WITH END COLOSTOM,44206,HCPCS,360,RC,7212071,CDM,,OUTPATIENT,,,13744,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF ILEOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44314,HCPCS,360,RC,7212057,CDM,,OUTPATIENT,,,3301.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,960,RC,44320,CDM,,OUTPATIENT,,,2282,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLOSTOMY OR SKIN LEVEL CECOSTOMY,44320,HCPCS,360,RC,7212001,CDM,,OUTPATIENT,,,3318,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REVISION OF COLOSTOMY COMPLICATED (RECONSTRUCTION IN-DEPTH),44345,HCPCS,960,RC,44345,CDM,,OUTPATIENT,,,2586.33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,750,RC,7210044,CDM,,OUTPATIENT,,,5322,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY BEYOND SECOND PORTIO,44372,HCPCS,360,RC,44372,CDM,,OUTPATIENT,,,5322,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7210045,CDM,,OUTPATIENT,,,2036.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILEOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44382,HCPCS,750,RC,7212061,CDM,,OUTPATIENT,,,2889,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA DIAGNOSTIC INCLUDING COLLECTION,44388,HCPCS,750,RC,7210029,CDM,,OUTPATIENT,,,2600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,360,RC,44389,CDM,,OUTPATIENT,,,3398,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH BIOPSY SINGLE OR MULTIPLE,44389,HCPCS,750,RC,7210028,CDM,,OUTPATIENT,,,3398,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH REMOVAL OF TUMOR(S) POLYP(S,44394,HCPCS,750,RC,7210036,CDM,,OUTPATIENT,,,2046.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,44403,HCPCS,360,RC,44403,CDM,,OUTPATIENT,,,3398,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY THROUGH STOMA WITH DIRECTED SUBMUCOSAL INJECTIO,44404,HCPCS,750,RC,7210046,CDM,,OUTPATIENT,,,2046.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE,44620,HCPCS,960,RC,44620,CDM,,OUTPATIENT,,,2131.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOSURE OF ENTEROSTOMY LARGE OR SMALL INTESTINE WITH RESEC,44626,HCPCS,960,RC,44626,CDM,,OUTPATIENT,,,3422.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA PROF,44650,HCPCS,981,RC,6235071,CDM,,OUTPATIENT,,,748,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY,44950,HCPCS,360,RC,44950,CDM,,OUTPATIENT,,,10424,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS OR GENERALI,44960,HCPCS,960,RC,44960,CDM,,OUTPATIENT,,,2132.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL APPENDECTOMY,44970,HCPCS,360,RC,44970,CDM,,OUTPATIENT,,,15503,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF ANORECTAL WALL ANAL APPROACH (EG CONGENITAL MEGA,45100,HCPCS,960,RC,45100,CDM,,OUTPATIENT,,,722.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF RECTAL TUMOR TRANSANAL APPROACH NOT INCLUDING,45171,HCPCS,360,RC,7211059,CDM,,OUTPATIENT,,,7485,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,750,RC,7210017,CDM,,OUTPATIENT,,,2600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID DIAGNOSTIC WITH OR WITHOUT COLL,45300,HCPCS,360,RC,45300,CDM,,OUTPATIENT,,,2600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH BIOPSY SINGLE OR MULTIPLE,45305,HCPCS,750,RC,7210018,CDM,,OUTPATIENT,,,1973.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCTOSIGMOIDOSCOPY RIGID WITH REMOVAL OF FOREIGN BODY,45307,HCPCS,750,RC,7210050,CDM,,OUTPATIENT,,,5023.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF,45330,HCPCS,360,RC,45330,CDM,,OUTPATIENT,,,2600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,45330,HCPCS,750,RC,7210011,CDM,,OUTPATIENT,,,2600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,360,RC,45331,CDM,,OUTPATIENT,,,2600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45331,HCPCS,750,RC,7210012,CDM,,OUTPATIENT,,,2600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45332,HCPCS,750,RC,7210039,CDM,,OUTPATIENT,,,2034.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(,45335,HCPCS,750,RC,7210015,CDM,,OUTPATIENT,,,1547.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,360,RC,453370,CDM,,OUTPATIENT,,,2600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC,45337,HCPCS,960,RC,45337,CDM,,OUTPATIENT,,,226.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45338,HCPCS,750,RC,7210013,CDM,,OUTPATIENT,,,2134.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATI,45340,HCPCS,750,RC,7210016,CDM,,OUTPATIENT,,,3398,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45346,HCPCS,750,RC,7210014,CDM,,OUTPATIENT,,,1850.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SIGMOIDOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45349,HCPCS,750,RC,7210048,CDM,,OUTPATIENT,,,8004,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,45378,HCPCS,750,RC,45378,CDM,,OUTPATIENT,,,2600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),45379,HCPCS,750,RC,7210027,CDM,,OUTPATIENT,,,2136.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,960,RC,45380,CDM,,OUTPATIENT,,,660.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE,45380,HCPCS,750,RC,7210022,CDM,,OUTPATIENT,,,3398,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,7210024,CDM,,OUTPATIENT,,,3398,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DIRECTED SUBMUCOSAL INJECTION(S),45381,HCPCS,750,RC,45381,CDM,,OUTPATIENT,,,3398,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,960,RC,45382,CDM,,OUTPATIENT,,,841.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH CONTROL OF BLEEDING ANY METHOD,45382,HCPCS,750,RC,7210037,CDM,,OUTPATIENT,,,3398,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45384,HCPCS,750,RC,7210026,CDM,,OUTPATIENT,,,2034.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,960,RC,45385,CDM,,OUTPATIENT,,,907.43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) O,45385,HCPCS,750,RC,7210023,CDM,,OUTPATIENT,,,3398,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION,45386,HCPCS,750,RC,7210030,CDM,,OUTPATIENT,,,949.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ABLATION OF TUMOR(S) POLYP(S),45388,HCPCS,750,RC,7210025,CDM,,OUTPATIENT,,,2034.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,960,RC,45390,CDM,,OUTPATIENT,,,771.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH ENDOSCOPIC MUCOSAL RESECTION,45390,HCPCS,750,RC,7210049,CDM,,OUTPATIENT,,,8004,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,960,RC,45393,CDM,,OUTPATIENT,,,629.33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH DECOMPRESSION (FOR PATHOLOGIC DI,45393,HCPCS,750,RC,7210031,CDM,,OUTPATIENT,,,2034.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,750,RC,453980,CDM,,OUTPATIENT,,,3398,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),45398,HCPCS,960,RC,45398,CDM,,OUTPATIENT,,,448,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDU,45915,HCPCS,360,RC,45915,CDM,,OUTPATIENT,,,3177,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,360,RC,46040,CDM,,OUTPATIENT,,,3177,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230120,CDM,,OUTPATIENT,,,829,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,450,RC,6230263,CDM,,OUTPATIENT,,,3790,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSC,46040,HCPCS,981,RC,6230124,CDM,,OUTPATIENT,,,2469.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,6230218,CDM,,OUTPATIENT,,,171,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,46083,HCPCS,981,RC,6230097,CDM,,OUTPATIENT,,,264,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION OF THROMBOSED HEMORRHOID EXTERNAL,46083,HCPCS,450,RC,460830,CDM,,OUTPATIENT,,,171,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,360,RC,7212006,CDM,,OUTPATIENT,,,3177,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,46220,HCPCS,960,RC,46220,CDM,,OUTPATIENT,,,230,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY RUBBER BAND LIGATION(S),46221,HCPCS,360,RC,46221,CDM,,OUTPATIENT,,,2431,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP,46250,HCPCS,360,RC,46250,CDM,,OUTPATIENT,,,4990,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SINGLE COLUMN/GROUP,46255,HCPCS,360,RC,46255,CDM,,OUTPATIENT,,,7485,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 2 OR MORE COLUMNS/G,46260,HCPCS,360,RC,46260,CDM,,OUTPATIENT,,,7485,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SURG TX ANAL FISTULA SUBQ,46270,HCPCS,360,RC,46270,CDM,,OUTPATIENT,,,8004,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF THROMBOSED HEMORRHOID EXTERNAL,46320,HCPCS,360,RC,46320,CDM,,OUTPATIENT,,,3177,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,981,RC,6235027,CDM,,OUTPATIENT,,,138,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,450,RC,6230153,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANOSCOPY DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN(S) BY,46600,HCPCS,750,RC,7210019,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MO,46922,HCPCS,360,RC,46922,CDM,,OUTPATIENT,,,7485,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG,46930,HCPCS,960,RC,46930,CDM,,OUTPATIENT,,,337.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMORRHOIDECTOMY INTERNAL BY LIGATION OTHER THAN RUBBER BA,46946,HCPCS,960,RC,46946,CDM,,OUTPATIENT,,,544.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,47000,HCPCS,320,RC,47000,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX,47480,HCPCS,960,RC,47480,CDM,,OUTPATIENT,,,1666,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX CHOLANGIO PRQ W/IMG GID RS ANDI EXISTING ACCESS,47531,HCPCS,361,RC,7040013,CDM,,OUTPATIENT,,,10424,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION PROCEDURE FOR CHOLANGIOGRAPHY PERCUTANEOUS COMPL,47531,HCPCS,960,RC,7505223,CDM,,OUTPATIENT,,,148.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY,47562,HCPCS,360,RC,47562,CDM,,OUTPATIENT,,,15503,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,47563,HCPCS,360,RC,47563,CDM,,OUTPATIENT,,,16578,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH EXPLORATION OF C,47564,HCPCS,360,RC,7212060,CDM,,OUTPATIENT,,,18243,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLECYSTECTOMY,47600,HCPCS,960,RC,47600,CDM,,OUTPATIENT,,,2611.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXPLORATORY LAPAROTOMY EXPLORATORY CELIOTOMY WITH OR WITHOU,49000,HCPCS,960,RC,49000,CDM,,OUTPATIENT,,,1882.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,49082,HCPCS,981,RC,6235002,CDM,,OUTPATIENT,,,140,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT,49082,HCPCS,960,RC,49082,CDM,,OUTPATIENT,,,140,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,972,RC,7505382,CDM,,OUTPATIENT,,,277.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,402,RC,7043055,CDM,,OUTPATIENT,,,2651,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,960,RC,49083,CDM,,OUTPATIENT,,,204,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMA,49083,HCPCS,350,RC,7042056,CDM,,OUTPATIENT,,,2651,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERITONEAL LAVAGE INCLUDING IMAGING GUIDANCE WHEN PERFORME,49084,HCPCS,360,RC,49084,CDM,,OUTPATIENT,,,2479,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,402,RC,7042014,CDM,,OUTPATIENT,,,3034.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY ABDOMINAL OR RETROPERITONEAL MASS PERCUTANEOUS NEED,49180,HCPCS,960,RC,7505016,CDM,,OUTPATIENT,,,191.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UMBILECTOMY OMPHALECTOMY EXCISION OF UMBILICUS (SEPARATE P,49250,HCPCS,360,RC,49250,CDM,,OUTPATIENT,,,9748,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY ABDOMEN PERITONEUM AND OMENTUM DIAGNOSTIC W,49320,HCPCS,360,RC,49320,CDM,,OUTPATIENT,,,15503,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH BIOPSY (SINGLE OR MULTIPLE),49321,HCPCS,360,RC,49321,CDM,,OUTPATIENT,,,15503,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49329 LAP PROCEDURE ABD PERITONEUM OMENTUM,49329,HCPCS,360,RC,49329,CDM,,OUTPATIENT,,,15503,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ,49405,HCPCS,350,RC,7040197,CDM,,OUTPATIENT,,,3034,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ,49406,HCPCS,330,RC,7040199,CDM,,OUTPATIENT,,,2874,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHNG ABSC/CST DRG CATH RAD GID SPX,49423,HCPCS,361,RC,7042015,CDM,,OUTPATIENT,,,3119.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHE,49423,HCPCS,960,RC,7505017,CDM,,OUTPATIENT,,,152.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF GASTROSTOMY TUBE PERCUTANEOUS UNDER FLUOROSCO,49440,HCPCS,360,RC,7212076,CDM,,OUTPATIENT,,,6096,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTIN,49465,HCPCS,960,RC,7505266,CDM,,OUTPATIENT,,,76.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR INJECTION CONTRAST FOR TUBE EVAL,49465,HCPCS,320,RC,7040056,CDM,,OUTPATIENT,,,754,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER REDUCI,49505,HCPCS,360,RC,49505,CDM,,OUTPATIENT,,,10424,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INGUINAL HERNIA AGE 5 YEARS OR OLDER INCARC,49507,HCPCS,360,RC,49507,CDM,,OUTPATIENT,,,10424,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
49520 REPAIR RECURRENT INGUINAL HERNIA ANY AGE REDUCIBLE,49520,HCPCS,360,RC,49520,CDM,,OUTPATIENT,,,9748,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INGUINAL HERNIA ANY AGE INCARCERATED OR S,49521,HCPCS,360,RC,49521,CDM,,OUTPATIENT,,,10424,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL FEMORAL HERNIA ANY AGE INCARCERATED OR STRA,49553,HCPCS,360,RC,49553,CDM,,OUTPATIENT,,,10626,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA REDUCIBLE,49560,HCPCS,360,RC,49560,CDM,,OUTPATIENT,,,9748,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA INCARCERATED OR,49561,HCPCS,360,RC,49561,CDM,,OUTPATIENT,,,9748,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA INCARCERATED,49566,HCPCS,360,RC,49566,CDM,,OUTPATIENT,,,15503,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR OPEN INCISIONAL,49568,HCPCS,960,RC,49568,CDM,,OUTPATIENT,,,649.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER REDUCIBLE,49585,HCPCS,360,RC,49585,CDM,,OUTPATIENT,,,9748,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR UMBILICAL HERNIA AGE 5 YEARS OR OLDER INCARCERATED,49587,HCPCS,360,RC,49587,CDM,,OUTPATIENT,,,10424,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49591,HCPCS,360,RC,8020000,CDM,,OUTPATIENT,,,12397,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49592,HCPCS,360,RC,7212027,CDM,,OUTPATIENT,,,15636,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE EPIGASTRIC INCI,49594,HCPCS,360,RC,7212026,CDM,,OUTPATIENT,,,15636,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL REPAIR INITIAL INGUINAL HERNIA,49650,HCPCS,360,RC,49650,CDM,,OUTPATIENT,,,15503,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN,49900,HCPCS,360,RC,7211061,CDM,,OUTPATIENT,,,2200,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE TECH,51100,HCPCS,450,RC,6230156,CDM,,OUTPATIENT,,,1236,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51100 ASPIRATOIN OF BLADDER BY NEEDLE PROF,51100,HCPCS,981,RC,6235029,CDM,,OUTPATIENT,,,91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION FOR BLADDER X-RAY,51610,HCPCS,339,RC,7040196,CDM,,OUTPATIENT,,,75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,981,RC,6235030,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,450,RC,6230157,CDM,,OUTPATIENT,,,872,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLADDER IRRIGATION SIMPLE LAVAGE AND/OR INSTILLATION,51700,HCPCS,360,RC,51700,CDM,,OUTPATIENT,,,872,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,450,RC,517010,CDM,,OUTPATIENT,,,345,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT C,51701,HCPCS,360,RC,51701,CDM,,OUTPATIENT,,,345,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,51702,HCPCS,519,RC,51702,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,517021,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,450,RC,6230125,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE (,51702,HCPCS,,,517020,CDM,,OUTPATIENT,,,46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER COMPLICA,51703,HCPCS,360,RC,51703,CDM,,OUTPATIENT,,,428,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,450,RC,517050,CDM,,OUTPATIENT,,,872,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHANGE OF CYSTOSTOMY TUBE SIMPLE,51705,HCPCS,360,RC,7212077,CDM,,OUTPATIENT,,,752,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL,51715,HCPCS,360,RC,51715,CDM,,OUTPATIENT,,,9420,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
51720: INTRODUCTION PROCEDURE ON THE BLADDER,51720,HCPCS,510,RC,51720,CDM,,OUTPATIENT,,,62.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,,,51798,CDM,,OUTPATIENT,,,171,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CA,51798,HCPCS,450,RC,6230262,CDM,,OUTPATIENT,,,201,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),52000,HCPCS,360,RC,52000,CDM,,OUTPATIENT,,,1763,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION WITH OR WI,52005,HCPCS,360,RC,7212074,CDM,,OUTPATIENT,,,6492,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH BIOPSY(S),52204,HCPCS,360,RC,52204,CDM,,OUTPATIENT,,,5486,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52224,HCPCS,360,RC,7212011,CDM,,OUTPATIENT,,,9420,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52234,HCPCS,360,RC,52234,CDM,,OUTPATIENT,,,11218,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH FULGURATION (INCLUDING CRYOSURGERY O,52235,HCPCS,360,RC,52235,CDM,,OUTPATIENT,,,9420,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY W/DEST AND/RMVL TUMOR LARGE,52240,HCPCS,360,RC,52240,CDM,,OUTPATIENT,,,13518,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH CALIBRATION AND/OR DILATION OF URETH,52281,HCPCS,360,RC,7212047,CDM,,OUTPATIENT,,,6492,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,52281,HCPCS,960,RC,52281,CDM,,OUTPATIENT,,,426,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INJECTION(S) FOR CHEMODENERVATION OF,52287,HCPCS,360,RC,52287,CDM,,OUTPATIENT,,,5565,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH REMOVAL OF FOREIGN BODY CALCULUS O,52310,HCPCS,360,RC,52310,CDM,,OUTPATIENT,,,5486,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOURETHROSCOPY WITH INSERTION OF INDWELLING URETERAL STE,52332,HCPCS,360,RC,52332,CDM,,OUTPATIENT,,,9420,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE INCLUDI,52601,HCPCS,360,RC,52601,CDM,,OUTPATIENT,,,13518,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLU,53446,HCPCS,360,RC,7212072,CDM,,OUTPATIENT,,,16458,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54055,HCPCS,360,RC,54055,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54056,HCPCS,960,RC,54056,CDM,,OUTPATIENT,,,157,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA M,54060,HCPCS,360,RC,54060,CDM,,OUTPATIENT,,,5248,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION USING CLAMP OR OTHER DEVICE WITH REGIONAL DORS,54150,HCPCS,360,RC,54150,CDM,,OUTPATIENT,,,5866,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CIRCUMCISION SURGICAL EXCISION OTHER THAN CLAMP DEVICE OR,54161,HCPCS,360,RC,54161,CDM,,OUTPATIENT,,,5486,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIECTOMY SIMPLE (INCLUDING SUBCAPSULAR) WITH OR WITHOUT,54520,HCPCS,360,RC,54520,CDM,,OUTPATIENT,,,9420,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORCHIOPEXY INGUINAL OR SCROTAL APPROACH,54640,HCPCS,360,RC,7212043,CDM,,OUTPATIENT,,,12397,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF EPIDIDYMIS TESTIS AND/OR SCROTAL S,54700,HCPCS,360,RC,7212073,CDM,,OUTPATIENT,,,6492,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LOCAL LESION OF EPIDIDYMIS,54830,HCPCS,360,RC,7212052,CDM,,OUTPATIENT,,,11218,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF SPERMATOCELE WITH OR WITHOUT EPIDIDYMECTOMY,54840,HCPCS,360,RC,54840,CDM,,OUTPATIENT,,,5486,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE UNILATERAL,55040,HCPCS,360,RC,55040,CDM,,OUTPATIENT,,,9748,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF HYDROCELE BILATERAL,55041,HCPCS,360,RC,55041,CDM,,OUTPATIENT,,,9748,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,360,RC,55100,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE OF SCROTAL WALL ABSCESS,55100,HCPCS,450,RC,6230076,CDM,,OUTPATIENT,,,4610,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCROTAL EXPLORATION,55110,HCPCS,360,RC,55110,CDM,,OUTPATIENT,,,10074,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY IN SCROTUM,55120,HCPCS,360,RC,55120,CDM,,OUTPATIENT,,,5486,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,55250,HCPCS,360,RC,55250,CDM,,OUTPATIENT,,,5866,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY PROSTATE NEEDLE OR PUNCH SINGLE OR MULTIPLE ANY A,55700,HCPCS,360,RC,55700,CDM,,OUTPATIENT,,,5866,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,450,RC,56405,CDM,,OUTPATIENT,,,640,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,56405,HCPCS,360,RC,7212037,CDM,,OUTPATIENT,,,876,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ID OF BARTHOLINS GLAND ABSCESS,56420,HCPCS,450,RC,564200,CDM,,OUTPATIENT,,,352,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYSIS OF LABIAL ADHESIONS,56441,HCPCS,360,RC,56441,CDM,,OUTPATIENT,,,8039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE) 1 LESION,56605,HCPCS,360,RC,56605,CDM,,OUTPATIENT,,,1942,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY OF VAGINAL MUCOSA SIMPLE (SEPARATE PROCEDURE),57100,HCPCS,360,RC,57100,CDM,,OUTPATIENT,,,1942,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOCLEISIS (LE FORT TYPE),57120,HCPCS,360,RC,7212031,CDM,,OUTPATIENT,,,13905,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPO,57160,HCPCS,360,RC,57160,CDM,,OUTPATIENT,,,522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTERIOR COLPORRHAPHY REPAIR OF CYSTOCELE WITH OR WITHOUT R,57240,HCPCS,360,RC,57240,CDM,,OUTPATIENT,,,13510,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY,57250,HCPCS,360,RC,57250,CDM,,OUTPATIENT,,,9007,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPAIR OF ENTEROCELE VAGINAL APPROACH (SEPARATE PROCEDURE),57268,HCPCS,360,RC,57268,CDM,,OUTPATIENT,,,13510,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLING OPERATION FOR STRESS INCONTINENCE (EG FASCIA OR SYNTH,57288,HCPCS,360,RC,7212042,CDM,,OUTPATIENT,,,16223,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),57410,HCPCS,360,RC,57410,CDM,,OUTPATIENT,,,8039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE ENTIRE VAGINA WITH CERVIX IF PRESENT WIT,57421,HCPCS,960,RC,57421,CDM,,OUTPATIENT,,,172,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA,57452,HCPCS,360,RC,57452,CDM,,OUTPATIENT,,,522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA WI,57454,HCPCS,360,RC,57454,CDM,,OUTPATIENT,,,864,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONIZATION CERVIX W/WO DC RPR ELTRD EXC,57522,HCPCS,360,RC,7212010,CDM,,OUTPATIENT,,,8039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,58100,HCPCS,360,RC,58100,CDM,,OUTPATIENT,,,522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY,58110,HCPCS,960,RC,58110,CDM,,OUTPATIENT,,,95.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DILATION AND CURETTAGE DIAGNOSTIC AND/OR THERAPEUTIC (NONOB,58120,HCPCS,360,RC,7212035,CDM,,OUTPATIENT,,,8482.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX) WITH OR WI,58150,HCPCS,960,RC,58150,CDM,,OUTPATIENT,,,2101.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,360,RC,7212032,CDM,,OUTPATIENT,,,13905,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL HYSTERECTOMY FOR UTERUS 250 G OR LESS,58260,HCPCS,960,RC,58260,CDM,,OUTPATIENT,,,1661.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAG HYST 250 GM/< W/RMVL TUBE AND/OVARY,58262,HCPCS,360,RC,58262,CDM,,OUTPATIENT,,,13510,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58300: IUD INSERTION,58300,HCPCS,510,RC,58300,CDM,,OUTPATIENT,,,172.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,450,RC,6230077,CDM,,OUTPATIENT,,,924,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,7046144,CDM,,OUTPATIENT,,,924,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,360,RC,58301,CDM,,OUTPATIENT,,,924,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENDOMETRIAL ABLATION THERMAL WITHOUT HYSTEROSCOPIC GUIDANC,58353,HCPCS,360,RC,58353,CDM,,OUTPATIENT,,,14448,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58552,HCPCS,360,RC,58552,CDM,,OUTPATIENT,,,27289,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH VAGINAL HYSTERECTOMY FOR UTERUS,58554,HCPCS,360,RC,58554,CDM,,OUTPATIENT,,,27289,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH SAMPLING (BIOPSY) OF ENDOMETRIU,58558,HCPCS,360,RC,58558,CDM,,OUTPATIENT,,,8039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,960,RC,58561,CDM,,OUTPATIENT,,,684,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYSTEROSCOPY SURGICAL WITH REMOVAL OF LEIOMYOMATA,58561,HCPCS,360,RC,7212004,CDM,,OUTPATIENT,,,13510,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX,58605,HCPCS,960,RC,58605,CDM,,OUTPATIENT,,,846,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT TH,58611,HCPCS,960,RC,58611,CDM,,OUTPATIENT,,,157.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH REMOVAL OF ADNEXAL STRUCTURES (P,58661,HCPCS,360,RC,58661,CDM,,OUTPATIENT,,,15503,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OR EXCISION OF LESIO,58662,HCPCS,360,RC,58662,CDM,,OUTPATIENT,,,15503,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAPAROSCOPY SURGICAL WITH FULGURATION OF OVIDUCTS (WITH OR,58670,HCPCS,360,RC,58670,CDM,,OUTPATIENT,,,16578,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVARIAN CYSTECTOMY UNILATERAL OR BILATERAL,58925,HCPCS,360,RC,58925,CDM,,OUTPATIENT,,,13510,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,59025,CDM,,OUTPATIENT,,,534,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL NON-STRESS TEST,59025,HCPCS,720,RC,6080002,CDM,,OUTPATIENT,,,558,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSERTION OF CERVICAL DILATOR (EG LAMINARIA PROSTAGLANDIN),59200,HCPCS,360,RC,59200,CDM,,OUTPATIENT,,,864,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE VAGINAL DE,59400,HCPCS,960,RC,59400,CDM,,OUTPATIENT,,,3716.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59409,HCPCS,360,RC,59409,CDM,,OUTPATIENT,,,8039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FOR,59410,HCPCS,960,RC,59410,CDM,,OUTPATIENT,,,1841.64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,59412,HCPCS,360,RC,59412,CDM,,OUTPATIENT,,,8039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),59414,HCPCS,360,RC,59414,CDM,,OUTPATIENT,,,8039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,960,RC,59425,CDM,,OUTPATIENT,,,632.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,960,RC,59426,CDM,,OUTPATIENT,,,1116.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,960,RC,59430,CDM,,OUTPATIENT,,,279.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE CESAREAN D,59510,HCPCS,960,RC,59510,CDM,,OUTPATIENT,,,4102.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY,59514,HCPCS,960,RC,59514,CDM,,OUTPATIENT,,,2262.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE,59515,HCPCS,960,RC,59515,CDM,,OUTPATIENT,,,3108,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF INCOMPLETE ABORTION ANY TRIMESTER COMPLETED S,59812,HCPCS,360,RC,59812,CDM,,OUTPATIENT,,,8039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF MISSED ABORTION COMPLETED SURGICALLY FIRST TR,59820,HCPCS,360,RC,59820,CDM,,OUTPATIENT,,,8039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX MISSED ABORTION SECOND TRIMESTER SURGICAL,59821,HCPCS,960,RC,59821,CDM,,OUTPATIENT,,,710,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,360,RC,62270,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,361,RC,65122,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,62270,HCPCS,450,RC,6235001,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINAL PUNCTURE THERAPEUTIC FOR DRAINAGE OF CEREBROSPINAL,62272,HCPCS,360,RC,62272,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,450,RC,6230217,CDM,,OUTPATIENT,,,1476,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EPIDURAL OF BLOOD OR CLOT PATCH,62273,HCPCS,370,RC,62273,CDM,,OUTPATIENT,,,1433,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARTHROCENTESIS ASPIR AND/INJ INTERM JT/BURS W/O US,62273,HCPCS,981,RC,6230095,CDM,,OUTPATIENT,,,738,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62321 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62321,HCPCS,761,RC,62321,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN,62321,HCPCS,510,RC,7420004,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE SINGLE EPI/SPIN LUMB/SAC STEROID,62322,HCPCS,370,RC,62322,CDM,,OUTPATIENT,,,1433,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN,62323,HCPCS,510,RC,7420005,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
62323 INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S,62323,HCPCS,761,RC,62323,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL CERV/THOR POSTOP,62324,HCPCS,370,RC,62324,CDM,,OUTPATIENT,,,1426,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPINE W/CATH EPI/SPINAL LUMB/SACRAL POSTOP,62326,HCPCS,370,RC,62326,CDM,,OUTPATIENT,,,1600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,981,RC,64400,CDM,,OUTPATIENT,,,176,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,644001,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRIGEMINAL,64400,HCPCS,450,RC,6230078,CDM,,OUTPATIENT,,,856,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,450,RC,6230199,CDM,,OUTPATIENT,,,858,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,360,RC,644051,CDM,,OUTPATIENT,,,858,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID GREATER OC,64405,HCPCS,,,6230090,CDM,,OUTPATIENT,,,708.64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK BRACHIAL PLEXUS,64415,HCPCS,370,RC,64415,CDM,,OUTPATIENT,,,1437,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID AXILLARY N,64417,HCPCS,370,RC,64417,CDM,,OUTPATIENT,,,1436.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64420,HCPCS,510,RC,7420006,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTERCOSTAL NERVE SINGLE LEVEL,64420,HCPCS,370,RC,64420,CDM,,OUTPATIENT,,,1297,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,510,RC,7420007,CDM,,OUTPATIENT,,,2697,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID INTERCOSTA,64421,HCPCS,761,RC,64421,CDM,,OUTPATIENT,,,2697,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ILIOINGUINAL ILIOHYPOGASTRIC NERVE,64425,HCPCS,370,RC,64425,CDM,,OUTPATIENT,,,1154,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCIATIC NERVE SINGLE,64445,HCPCS,370,RC,64445,CDM,,OUTPATIENT,,,1433,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NE,64447,HCPCS,370,RC,7046135,CDM,,OUTPATIENT,,,1174.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,64447,CDM,,OUTPATIENT,,,1140,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL SINGLE,64447,HCPCS,761,RC,7046136,CDM,,OUTPATIENT,,,1140,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK FEMORAL NERVE CONINUOUS BY CATH,64448,HCPCS,370,RC,64448,CDM,,OUTPATIENT,,,1437,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE BLOCK OTHER PERIPHERAL NERVE (IPACK),64450,HCPCS,370,RC,64450,CDM,,OUTPATIENT,,,1140,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID OTHER PERI,64450,HCPCS,450,RC,6230220,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,510,RC,644500,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,64450,HCPCS,981,RC,6230098,CDM,,OUTPATIENT,,,178,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION AA AND/STRD OTHER PERIPHERAL NERVE/BRANCH,64450,HCPCS,450,RC,6230201,CDM,,OUTPATIENT,,,2081,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENICULAR NERVE BRANCHES,64454,HCPCS,370,RC,64454,CDM,,OUTPATIENT,,,1297,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PLANTAR CO,64455,HCPCS,360,RC,64455,CDM,,OUTPATIENT,,,800,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64479,HCPCS,360,RC,64479,CDM,,OUTPATIENT,,,2522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID TRANSFORAM,64480,HCPCS,960,RC,64480,CDM,,OUTPATIENT,,,263.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64483 INJECTION TRANSFORAMINAL EPIDURAL - SINGLE LEVEL,64483,HCPCS,761,RC,64483,CDM,,OUTPATIENT,,,2697,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX AA AND/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL,64483,HCPCS,510,RC,7420008,CDM,,OUTPATIENT,,,2697,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSVERSUS ABDOMINIS PLAN TAP BLOCK,64486,HCPCS,370,RC,64486,CDM,,OUTPATIENT,,,1681,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAP BLOCK,64488,HCPCS,370,RC,64488,CDM,,OUTPATIENT,,,1281,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64490 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64490,HCPCS,761,RC,64490,CDM,,OUTPATIENT,,,2697,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,64490,HCPCS,510,RC,7420009,CDM,,OUTPATIENT,,,2697,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64491 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64491,HCPCS,960,RC,64491,CDM,,OUTPATIENT,,,111.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL,64491,HCPCS,761,RC,7420010,CDM,,OUTPATIENT,,,494.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL,64492,HCPCS,761,RC,7420011,CDM,,OUTPATIENT,,,494.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64492 INJECTION PARAVERTEBRAL FACET JOINT - CERVICAL OR THOR,64492,HCPCS,960,RC,64492,CDM,,OUTPATIENT,,,112.27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64493 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64493,HCPCS,761,RC,64493,CDM,,OUTPATIENT,,,2697,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL,64493,HCPCS,761,RC,7420012,CDM,,OUTPATIENT,,,2697,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL,64494,HCPCS,761,RC,7420013,CDM,,OUTPATIENT,,,494.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64494 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64494,HCPCS,960,RC,64494,CDM,,OUTPATIENT,,,90.64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64495 INJECTION PARAVERTEBRAL FACET JOINT - LUMBAR OR SACRAL,64495,HCPCS,960,RC,64495,CDM,,OUTPATIENT,,,122.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL,64495,HCPCS,761,RC,7420014,CDM,,OUTPATIENT,,,494.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NJX ANES STELLATE GANGLION CRV SYMPATHETIC,64510,HCPCS,360,RC,64510,CDM,,OUTPATIENT,,,2522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY /TRANSPOSITION ULNAR NERVE WRIST,64719,HCPCS,960,RC,64719,CDM,,OUTPATIENT,,,772,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROPLASTY AND/OR TRANSPOSITION MEDIAN NERVE AT CARPAL TUN,64721,HCPCS,360,RC,64721,CDM,,OUTPATIENT,,,5753,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA CUTANEOUS NERVE,64788,HCPCS,360,RC,64788,CDM,,OUTPATIENT,,,5380,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
64999 BIER BLOCK,64999,HCPCS,370,RC,64999,CDM,,OUTPATIENT,,,1140,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES. 1/4 HOUR,65001,HCPCS,370,RC,65001,CDM,,OUTPATIENT,,,126.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE TECH,65205,HCPCS,450,RC,6230158,CDM,,OUTPATIENT,,,323,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65205 REMOVAL OF FOREIGN BODY EXTERNAL EYE PROF,65205,HCPCS,981,RC,6235031,CDM,,OUTPATIENT,,,175,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,6230236,CDM,,OUTPATIENT,,,230,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED TECH,65210,HCPCS,450,RC,6230159,CDM,,OUTPATIENT,,,593,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
65210 REMOVAL OF FOREIGN BODY CONJUNCTIVAL EMBEDDED PROF,65210,HCPCS,981,RC,6235032,CDM,,OUTPATIENT,,,175,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,6230249,CDM,,OUTPATIENT,,,1321,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,450,RC,652200,CDM,,OUTPATIENT,,,889,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITHOUT SLIT,65220,HCPCS,981,RC,6230107,CDM,,OUTPATIENT,,,59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230081,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,450,RC,6230160,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF FOREIGN BODY EXTERNAL EYE CORNEAL WITH SLIT LA,65222,HCPCS,981,RC,6235033,CDM,,OUTPATIENT,,,170,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL ASPIRATION TECHNIQUE 1 OR MORE ST,66840,HCPCS,360,RC,7212063,CDM,,OUTPATIENT,,,7558,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF LENS MATERIAL PHACOFRAGMENTATION TECHNIQUE (MECH,66850,HCPCS,360,RC,7212056,CDM,,OUTPATIENT,,,7558,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG,66982,HCPCS,360,RC,7212018,CDM,,OUTPATIENT,,,6363,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67005,HCPCS,360,RC,7212058,CDM,,OUTPATIENT,,,7558,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL OF VITREOUS ANTERIOR APPROACH (OPEN SKY TECHNIQUE O,67010,HCPCS,360,RC,7212054,CDM,,OUTPATIENT,,,7558,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION OF LESION CONJUNCTIVA UP TO 1 CM,68110,HCPCS,360,RC,7212062,CDM,,OUTPATIENT,,,7400,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRAINAGE EXTERNAL EAR ABSCESS OR HEMATOMA SIMPLE,69000,HCPCS,450,RC,6230082,CDM,,OUTPATIENT,,,2039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BIOPSY EXTERNAL EAR,69100,HCPCS,360,RC,7212015,CDM,,OUTPATIENT,,,648,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,960,RC,69110,CDM,,OUTPATIENT,,,813,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,69110,HCPCS,360,RC,7212064,CDM,,OUTPATIENT,,,9041,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
69200 FOREIGN BODY REMOVAL EAR CANAL W/O ANSET,69200,HCPCS,360,RC,692000,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT G,69200,HCPCS,981,RC,6235023,CDM,,OUTPATIENT,,,137,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,360,RC,69209,CDM,,OUTPATIENT,,,182,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230083,CDM,,OUTPATIENT,,,182,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,69209,HCPCS,450,RC,6230150,CDM,,OUTPATIENT,,,182,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230021,CDM,,OUTPATIENT,,,129,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,450,RC,6230149,CDM,,OUTPATIENT,,,128.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATER,69210,HCPCS,981,RC,6235022,CDM,,OUTPATIENT,,,161,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION EYE FOR DETECTION OF FOREIGN BODY,70030,HCPCS,960,RC,7505254,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION MANDIBLE COMPLETE MINIMUM OF 4 VIE,70110,HCPCS,960,RC,7505275,CDM,,OUTPATIENT,,,32.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,7040065,CDM,,OUTPATIENT,,,280.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,7040022,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FACIAL BONES COMPLETE MINIMUM OF 3,70150,HCPCS,960,RC,7505232,CDM,,OUTPATIENT,,,32.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,7040066,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NASAL BONES COMPLETE MINIMUM OF 3,70160,HCPCS,960,RC,7505276,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ORBITS COMPLETE MINIMUM OF 4 VIEWS,70200,HCPCS,960,RC,7505278,CDM,,OUTPATIENT,,,35.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ORBITS COMPLETE 4+VWS,70200,HCPCS,320,RC,7040068,CDM,,OUTPATIENT,,,384.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE:REPORT,70220,HCPCS,960,RC,7505298,CDM,,OUTPATIENT,,,32.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SINUSES PARANASAL COMPLETE 3+VWS,70220,HCPCS,320,RC,7040088,CDM,,OUTPATIENT,,,278.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,320,RC,7040089,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SKULL LESS THAN 4 VIEWS,70250,HCPCS,960,RC,7505299,CDM,,OUTPATIENT,,,32.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,320,RC,7040105,CDM,,OUTPATIENT,,,384.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TEMPOROMANDIBULAR JOINT OPEN AND CL,70328,HCPCS,960,RC,7505316,CDM,,OUTPATIENT,,,26.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR NECK SOFT TISSUE,70360,HCPCS,320,RC,7040067,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION NECK SOFT TISSUE,70360,HCPCS,960,RC,7505277,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,351,RC,7042034,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70450,HCPCS,960,RC,7505035,CDM,,OUTPATIENT,,,103,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,960,RC,7505034,CDM,,OUTPATIENT,,,134.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITH CONTRAST MATERIAL(S,70460,HCPCS,351,RC,7042033,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,351,RC,7042032,CDM,,OUTPATIENT,,,1489.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY HEAD OR BRAIN WITHOUT CONTRAST MATERIA,70470,HCPCS,960,RC,7505033,CDM,,OUTPATIENT,,,154.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505056,CDM,,OUTPATIENT,,,128.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042055,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,350,RC,7042040,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70480,HCPCS,960,RC,7505041,CDM,,OUTPATIENT,,,128.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042054,CDM,,OUTPATIENT,,,1165.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505040,CDM,,OUTPATIENT,,,119.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,960,RC,7505055,CDM,,OUTPATIENT,,,119.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70481,HCPCS,350,RC,7042039,CDM,,OUTPATIENT,,,1165.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,960,RC,7505054,CDM,,OUTPATIENT,,,125.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ORBIT SELLA OR POSTERIOR FOSSA OR OUT,70482,HCPCS,350,RC,7042053,CDM,,OUTPATIENT,,,1302.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505050,CDM,,OUTPATIENT,,,138.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,960,RC,7505063,CDM,,OUTPATIENT,,,138.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042049,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70486,HCPCS,350,RC,7042063,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,972,RC,7505365,CDM,,OUTPATIENT,,,116.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,960,RC,7505049,CDM,,OUTPATIENT,,,115.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,350,RC,7042094,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITH CONTRAST MATER,70487,HCPCS,351,RC,7042048,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,960,RC,7505048,CDM,,OUTPATIENT,,,122.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY MAXILLOFACIAL AREA WITHOUT CONTRAST MA,70488,HCPCS,350,RC,7042047,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,350,RC,7042052,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70490,HCPCS,960,RC,7505053,CDM,,OUTPATIENT,,,155.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,960,RC,7505052,CDM,,OUTPATIENT,,,167.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST MATERIA,70491,HCPCS,350,RC,7042051,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,960,RC,7505051,CDM,,OUTPATIENT,,,175.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST MATE,70492,HCPCS,350,RC,7042050,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,70496,CDM,,OUTPATIENT,,,149.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,350,RC,7042009,CDM,,OUTPATIENT,,,789,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD WITH CONTRAST MATERI,70496,HCPCS,960,RC,7505011,CDM,,OUTPATIENT,,,153.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,960,RC,7505013,CDM,,OUTPATIENT,,,153.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,350,RC,7042011,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK WITH CONTRAST MATERI,70498,HCPCS,,,70498,CDM,,OUTPATIENT,,,149.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,610,RC,7044017,CDM,,OUTPATIENT,,,1439.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ORBIT FACE AND/OR,70543,HCPCS,960,RC,7505102,CDM,,OUTPATIENT,,,259.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,960,RC,7505086,CDM,,OUTPATIENT,,,145.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST MATER,70544,HCPCS,615,RC,7044001,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,960,RC,7505088,CDM,,OUTPATIENT,,,146.26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70547,HCPCS,615,RC,7044003,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,960,RC,7505087,CDM,,OUTPATIENT,,,217.33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST MATER,70549,HCPCS,615,RC,7044002,CDM,,OUTPATIENT,,,1538.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,960,RC,7505096,CDM,,OUTPATIENT,,,180.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70551,HCPCS,611,RC,7044011,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,960,RC,7505095,CDM,,OUTPATIENT,,,216.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70552,HCPCS,611,RC,7044010,CDM,,OUTPATIENT,,,1866.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,611,RC,7044009,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING BRAIN (INCLUDING BR,70553,HCPCS,960,RC,7505094,CDM,,OUTPATIENT,,,286.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,710450,CDM,,OUTPATIENT,,,28.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040124,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW,71045,HCPCS,972,RC,7505388,CDM,,OUTPATIENT,,,24.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAM CHEST SINGLE VIEW,71045,HCPCS,324,RC,7040123,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,324,RC,7040125,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 2 VIEWS,71046,HCPCS,972,RC,71046,CDM,,OUTPATIENT,,,28.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CHEST 4 OR MORE VIEWS,71048,HCPCS,324,RC,7040126,CDM,,OUTPATIENT,,,266.77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,7040073,CDM,,OUTPATIENT,,,269.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,7040072,CDM,,OUTPATIENT,,,269.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505282,CDM,,OUTPATIENT,,,29.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL 2 VIEWS,71100,HCPCS,960,RC,7505283,CDM,,OUTPATIENT,,,29.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505286,CDM,,OUTPATIENT,,,33.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,7040076,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,7040077,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS UNILATERAL INCLUDING POSTEROA,71101,HCPCS,960,RC,7505287,CDM,,OUTPATIENT,,,33.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS 3 VIEWS BILATERAL,71110,HCPCS,320,RC,7040074,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL 3 VIEWS,71110,HCPCS,960,RC,7505284,CDM,,OUTPATIENT,,,33.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION RIBS BILATERAL INCLUDING POSTEROAN,71111,HCPCS,960,RC,7505285,CDM,,OUTPATIENT,,,38.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR RIBS W/ PA CHEST BILATERAL 4+VWS,71111,HCPCS,320,RC,7040075,CDM,,OUTPATIENT,,,361.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,7040103,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION STERNUM MINIMUM OF 2 VIEWS,71120,HCPCS,960,RC,7505314,CDM,,OUTPATIENT,,,26.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042083,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,350,RC,7042101,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,960,RC,7505018,CDM,,OUTPATIENT,,,121.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71250,HCPCS,972,RC,7505332,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,972,RC,7505354,CDM,,OUTPATIENT,,,151.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042105,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042082,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,350,RC,7042072,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITH CONTRAST MATER,71260,HCPCS,960,RC,7505072,CDM,,OUTPATIENT,,,150.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,972,RC,7505353,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,960,RC,7505071,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042071,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX DIAGNOSTIC WITHOUT CONTRAST MA,71270,HCPCS,350,RC,7042081,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORAX LOW DOSE FOR LUNG CANCER SCREEN,71271,HCPCS,960,RC,7505047,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT LOW DOSE LUNG SCREENING,71271,HCPCS,352,RC,7042046,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042010,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,350,RC,7042100,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505012,CDM,,OUTPATIENT,,,231.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST (NONCORONARY) WITH,71275,HCPCS,960,RC,7505331,CDM,,OUTPATIENT,,,231.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,71552,CDM,,OUTPATIENT,,,190.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,610,RC,7044012,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING CHEST (EG FOR EVAL,71552,HCPCS,960,RC,7505097,CDM,,OUTPATIENT,,,196.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,7040095,CDM,,OUTPATIENT,,,278.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505302,CDM,,OUTPATIENT,,,14.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE SINGLE VIEW SPECIFY LEVEL,72020,HCPCS,960,RC,7505306,CDM,,OUTPATIENT,,,14.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,7040091,CDM,,OUTPATIENT,,,278.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,7040092,CDM,,OUTPATIENT,,,355.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,960,RC,7505303,CDM,,OUTPATIENT,,,30.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,7040093,CDM,,OUTPATIENT,,,427.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,960,RC,7505304,CDM,,OUTPATIENT,,,39.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE CERVICAL 6 OR MORE VIEWS,72052,HCPCS,960,RC,7505305,CDM,,OUTPATIENT,,,43.26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE CERVICAL FLEX+EXT 6+VWS,72052,HCPCS,320,RC,7040094,CDM,,OUTPATIENT,,,427.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,7040102,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE THORACIC 2 VIEWS,72070,HCPCS,960,RC,7505313,CDM,,OUTPATIENT,,,29.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7040100,CDM,,OUTPATIENT,,,278.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72081,HCPCS,960,RC,7505311,CDM,,OUTPATIENT,,,37.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE ENTIRE THORACIC AND LUMBAR I,72082,HCPCS,960,RC,7505312,CDM,,OUTPATIENT,,,47.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7040101,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,960,RC,7505307,CDM,,OUTPATIENT,,,30.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,7040096,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL MINIMUM OF 4 VIE,72110,HCPCS,960,RC,7505308,CDM,,OUTPATIENT,,,39.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,7040097,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,7040099,CDM,,OUTPATIENT,,,469.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL COMPLETE INCLUD,72114,HCPCS,960,RC,7505310,CDM,,OUTPATIENT,,,41.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SPINE LUMBOSACRAL BENDING 2-3 VIEWS,72120,HCPCS,320,RC,7040098,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SPINE LUMBOSACRAL BENDING VIEWS ON,72120,HCPCS,960,RC,7505309,CDM,,OUTPATIENT,,,31.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,350,RC,7042064,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST MATERI,72125,HCPCS,960,RC,7505064,CDM,,OUTPATIENT,,,128.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST MATERIAL,72126,HCPCS,350,RC,7042095,CDM,,OUTPATIENT,,,1426.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,960,RC,7505069,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST MATERI,72128,HCPCS,350,RC,7042069,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST MATERIAL,72129,HCPCS,960,RC,7505068,CDM,,OUTPATIENT,,,487.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT THORACIC SPINE W/CONTRAST MATERIAL,72129,HCPCS,350,RC,7042068,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,960,RC,7505067,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72131,HCPCS,350,RC,7042067,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,350,RC,7042066,CDM,,OUTPATIENT,,,1207,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST MATERIAL,72132,HCPCS,960,RC,7505066,CDM,,OUTPATIENT,,,144.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,960,RC,7505065,CDM,,OUTPATIENT,,,112.27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST MATERIAL,72133,HCPCS,350,RC,7042065,CDM,,OUTPATIENT,,,1550.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,960,RC,7505135,CDM,,OUTPATIENT,,,192.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72141,HCPCS,612,RC,7044050,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,960,RC,7505134,CDM,,OUTPATIENT,,,232.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72142,HCPCS,612,RC,7044049,CDM,,OUTPATIENT,,,1866.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,612,RC,7044054,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72146,HCPCS,960,RC,7505139,CDM,,OUTPATIENT,,,192.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,960,RC,7505137,CDM,,OUTPATIENT,,,181.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72148,HCPCS,612,RC,7044052,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,960,RC,7505397,CDM,,OUTPATIENT,,,216.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72149,HCPCS,612,RC,7044068,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,612,RC,7044048,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72156,HCPCS,960,RC,7505133,CDM,,OUTPATIENT,,,312.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,960,RC,7505138,CDM,,OUTPATIENT,,,312.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72157,HCPCS,612,RC,7044053,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,612,RC,7044051,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING SPINAL CANAL AND CO,72158,HCPCS,960,RC,7505136,CDM,,OUTPATIENT,,,288.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,7040070,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS 1 OR 2 VIEWS,72170,HCPCS,960,RC,7505280,CDM,,OUTPATIENT,,,24.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION PELVIS COMPLETE MINIMUM OF 3 VIEWS,72190,HCPCS,960,RC,7505281,CDM,,OUTPATIENT,,,29.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,7040071,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,960,RC,7505058,CDM,,OUTPATIENT,,,129.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042058,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST MATERIAL,72192,HCPCS,350,RC,7042108,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042057,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,350,RC,7042103,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST MATERIAL(S),72193,HCPCS,960,RC,7505057,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,960,RC,7505126,CDM,,OUTPATIENT,,,178.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72195,HCPCS,610,RC,7044041,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,960,RC,7505125,CDM,,OUTPATIENT,,,271.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING PELVIS WITHOUT CON,72197,HCPCS,610,RC,7044040,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 1 OR 2 VIEWS,72200,HCPCS,320,RC,7040078,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS LESS THAN 3 VIEWS,72200,HCPCS,960,RC,7505288,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACROILIAC JOINTS 3 OR MORE VIEWS,72202,HCPCS,960,RC,7505289,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACROILIAC JOINTS 3+ VIEWS,72202,HCPCS,320,RC,7040079,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SACRUM AND COCCYX MINIMUM OF 2 VIEW,72220,HCPCS,960,RC,7505290,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,7040080,CDM,,OUTPATIENT,,,278.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505225,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CLAVICLE COMPLETE,73000,HCPCS,960,RC,7505224,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE LEFT,73000,HCPCS,320,RC,7040014,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CLAVICLE RIGHT,73000,HCPCS,320,RC,7040015,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505292,CDM,,OUTPATIENT,,,26.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA RIGHT,73010,HCPCS,320,RC,7040082,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SCAPULA LEFT,73010,HCPCS,320,RC,7040081,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SCAPULA COMPLETE,73010,HCPCS,960,RC,7505291,CDM,,OUTPATIENT,,,26.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505294,CDM,,OUTPATIENT,,,14.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER 1 VIEW,73020,HCPCS,960,RC,7505293,CDM,,OUTPATIENT,,,14.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,7040084,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,7040083,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505295,CDM,,OUTPATIENT,,,27.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,730300,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,75055296,CDM,,OUTPATIENT,,,27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,960,RC,7505296,CDM,,OUTPATIENT,,,27.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040086,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SHOULDER COMPLETE MINIMUM OF 2 VIE,73030,HCPCS,320,RC,7040085,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS RIGHT 2 VWS,73060,HCPCS,320,RC,7040055,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505265,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HUMERUS MINIMUM OF 2 VIEWS,73060,HCPCS,960,RC,7505264,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HUMERUS LEFT 2 VWS,73060,HCPCS,320,RC,7040054,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,7040018,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,7040017,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505227,CDM,,OUTPATIENT,,,15.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW 2 VIEWS,73070,HCPCS,960,RC,7505228,CDM,,OUTPATIENT,,,15.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505229,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,320,RC,7040020,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,7040019,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ELBOW COMPLETE MINIMUM OF 3 VIEWS,73080,HCPCS,960,RC,7505230,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,7040043,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,7040042,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505252,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOREARM 2 VIEWS,73090,HCPCS,960,RC,7505253,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,7040115,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505326,CDM,,OUTPATIENT,,,24.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST 2 VIEWS,73100,HCPCS,960,RC,7505327,CDM,,OUTPATIENT,,,24.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,7040116,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505329,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION WRIST COMPLETE MINIMUM OF 3 VIEWS,73110,HCPCS,960,RC,7505328,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,7040117,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,7040118,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505255,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND 2 VIEWS,73120,HCPCS,960,RC,7505256,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,7040046,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,7040045,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505258,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HAND MINIMUM OF 3 VIEWS,73130,HCPCS,960,RC,7505257,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,7040047,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,7040048,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505243,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505245,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT LEFT,73140,HCPCS,320,RC,7040026,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 2ND DIGIT RIGHT,73140,HCPCS,320,RC,7040027,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505241,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505240,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505239,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505238,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT LEFT,73140,HCPCS,320,RC,7040028,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 3RD DIGIT RIGHT,73140,HCPCS,320,RC,7040029,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT LEFT,73140,HCPCS,320,RC,7040030,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 4TH DIGIT RIGHT,73140,HCPCS,320,RC,7040031,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT LEFT,73140,HCPCS,320,RC,7040032,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS 5TH DIGIT RIGHT,73140,HCPCS,320,RC,7040033,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB LEFT,73140,HCPCS,320,RC,7040034,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FINGER 2+ VIEWS THUMB RIGHT,73140,HCPCS,320,RC,7040035,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505237,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505236,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505244,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FINGER(S) MINIMUM OF 2 VIEWS,73140,HCPCS,960,RC,7505242,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505370,CDM,,OUTPATIENT,,,121.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042017,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505077,CDM,,OUTPATIENT,,,117.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505062,CDM,,OUTPATIENT,,,117.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505061,CDM,,OUTPATIENT,,,117.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505039,CDM,,OUTPATIENT,,,117.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505032,CDM,,OUTPATIENT,,,117.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505031,CDM,,OUTPATIENT,,,117.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505020,CDM,,OUTPATIENT,,,117.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,960,RC,7505019,CDM,,OUTPATIENT,,,117.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042099,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042092,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042077,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042062,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042061,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042038,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042031,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042030,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,350,RC,7042018,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,2561026349,CDM,,OUTPATIENT,,,1085.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,2561026361,CDM,,OUTPATIENT,,,1085.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST MATER,73200,HCPCS,972,RC,7505363,CDM,,OUTPATIENT,,,121.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505369,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505368,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505362,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505359,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,972,RC,7505358,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505060,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505059,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505038,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505030,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,960,RC,7505028,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042098,CDM,,OUTPATIENT,,,1335.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042097,CDM,,OUTPATIENT,,,1335.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042091,CDM,,OUTPATIENT,,,1335.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042088,CDM,,OUTPATIENT,,,1335.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042087,CDM,,OUTPATIENT,,,1335.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042060,CDM,,OUTPATIENT,,,1336,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042059,CDM,,OUTPATIENT,,,1336,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042037,CDM,,OUTPATIENT,,,1336,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042029,CDM,,OUTPATIENT,,,1336,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST MATERIAL,73201,HCPCS,350,RC,7042026,CDM,,OUTPATIENT,,,1336,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505399,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044026,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044029,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044064,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044069,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505398,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,6235003,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044074,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505111,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,960,RC,7505114,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,972,RC,7505379,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73218,HCPCS,610,RC,7044070,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7505402,CDM,,OUTPATIENT,,,197.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73219,HCPCS,972,RC,7044073,CDM,,OUTPATIENT,,,197.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,73220,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,732200,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,732201,CDM,,OUTPATIENT,,,253.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044025,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044027,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044028,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044063,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044071,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,610,RC,7044072,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505110,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505112,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,960,RC,7505113,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505378,CDM,,OUTPATIENT,,,261.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505400,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING UPPER EXTREMITY OT,73220,HCPCS,972,RC,7505401,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505131,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505132,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505142,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505143,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044015,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505101,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044046,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044047,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044057,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044058,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,960,RC,7505100,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73221,HCPCS,610,RC,7044016,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505129,CDM,,OUTPATIENT,,,197.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,960,RC,7505130,CDM,,OUTPATIENT,,,197.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044044,CDM,,OUTPATIENT,,,1864.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73222,HCPCS,610,RC,7044045,CDM,,OUTPATIENT,,,1864.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044013,CDM,,OUTPATIENT,,,2236.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044014,CDM,,OUTPATIENT,,,2236.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044042,CDM,,OUTPATIENT,,,2236.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505128,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505098,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505099,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,960,RC,7505127,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF UPPER,73223,HCPCS,610,RC,7044043,CDM,,OUTPATIENT,,,2236.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505259,CDM,,OUTPATIENT,,,26.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS LEFT,73501,HCPCS,320,RC,7040049,CDM,,OUTPATIENT,,,278.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73501,HCPCS,960,RC,7505260,CDM,,OUTPATIENT,,,26.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 1 VIEW W/ AP PELVIS RIGHT,73502,HCPCS,320,RC,7040050,CDM,,OUTPATIENT,,,278.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7040052,CDM,,OUTPATIENT,,,278.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7040051,CDM,,OUTPATIENT,,,278.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505262,CDM,,OUTPATIENT,,,29.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP UNILATERAL WITH PELVIS WHEN PE,73502,HCPCS,960,RC,7505261,CDM,,OUTPATIENT,,,29.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIPS BILATERAL WITH PELVIS WHEN PE,73521,HCPCS,960,RC,7505263,CDM,,OUTPATIENT,,,35.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7040053,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI RIGHT,73525,HCPCS,320,RC,7040120,CDM,,OUTPATIENT,,,1042.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505384,CDM,,OUTPATIENT,,,74.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION HIP ARTHROGRAPHY RADIOLOGICAL SUPE,73525,HCPCS,972,RC,7505383,CDM,,OUTPATIENT,,,74.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM HIP SI LEFT,73525,HCPCS,320,RC,7040119,CDM,,OUTPATIENT,,,1042.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW RIGHT,73551,HCPCS,320,RC,7040023,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,960,RC,7505233,CDM,,OUTPATIENT,,,24.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR 1 VIEW,73551,HCPCS,972,RC,7505390,CDM,,OUTPATIENT,,,24.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 1 VIEW LEFT,73551,HCPCS,320,RC,7040127,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7040024,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7040025,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505234,CDM,,OUTPATIENT,,,25.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,73552,HCPCS,960,RC,7505235,CDM,,OUTPATIENT,,,25.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,7040059,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,7040060,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505270,CDM,,OUTPATIENT,,,26.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 1 OR 2 VIEWS,73560,HCPCS,960,RC,7505269,CDM,,OUTPATIENT,,,26.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505272,CDM,,OUTPATIENT,,,27.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE 3 VIEWS,73562,HCPCS,960,RC,7505271,CDM,,OUTPATIENT,,,27.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,7040062,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,7040061,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505274,CDM,,OUTPATIENT,,,31.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE COMPLETE 4 OR MORE VIEWS,73564,HCPCS,960,RC,7505273,CDM,,OUTPATIENT,,,31.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,7040063,CDM,,OUTPATIENT,,,466.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,7040064,CDM,,OUTPATIENT,,,466.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ARTHROGRAM KNEE SI RIGHT (CPT 73580 IS FOR THE IMAGING CO,73580,HCPCS,320,RC,7040007,CDM,,OUTPATIENT,,,1042.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505216,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION KNEE ARTHROGRAPHY RADIOLOGICAL SUP,73580,HCPCS,960,RC,7505215,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505318,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TIBIA AND FIBULA 2 VIEWS,73590,HCPCS,960,RC,7505317,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS LEFT,73590,HCPCS,320,RC,7040106,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TIBIA/FIBULA 2 VIEWS RIGHT,73590,HCPCS,320,RC,7040107,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,7040003,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,7040004,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505211,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,73600,HCPCS,960,RC,7505212,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,7040005,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,7040006,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505213,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ANKLE COMPLETE MINIMUM OF 3 VIEWS,73610,HCPCS,960,RC,7505214,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505248,CDM,,OUTPATIENT,,,14.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,7040038,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,7040039,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT 2 VIEWS,73620,HCPCS,960,RC,7505249,CDM,,OUTPATIENT,,,14.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505251,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION FOOT COMPLETE MINIMUM OF 3 VIEWS,73630,HCPCS,960,RC,7505250,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,7040040,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,7040041,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS LEFT,73650,HCPCS,320,RC,7040011,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505222,CDM,,OUTPATIENT,,,15.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION CALCANEUS MINIMUM OF 2 VIEWS,73650,HCPCS,960,RC,7505221,CDM,,OUTPATIENT,,,15.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CALCANEUS 2 VIEWS RIGHT,73650,HCPCS,320,RC,7040012,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505391,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505324,CDM,,OUTPATIENT,,,12.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505323,CDM,,OUTPATIENT,,,12.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505322,CDM,,OUTPATIENT,,,12.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT LEFT,73660,HCPCS,320,RC,7040128,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 2ND DIGIT RIGHT,73660,HCPCS,320,RC,7040129,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT LEFT,73660,HCPCS,320,RC,7040130,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 3RD DIGIT RIGHT,73660,HCPCS,320,RC,7040108,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT LEFT,73660,HCPCS,320,RC,7040109,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS 4TH DIGIT RIGHT,73660,HCPCS,320,RC,7040110,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT LEFT,73660,HCPCS,320,RC,7040112,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR TOES 2+ VIEWS GREAT RIGHT,73660,HCPCS,320,RC,7040113,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505393,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505321,CDM,,OUTPATIENT,,,12.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505320,CDM,,OUTPATIENT,,,12.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,972,RC,7505392,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,320,RC,7040111,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION TOE(S) MINIMUM OF 2 VIEWS,73660,HCPCS,960,RC,7505319,CDM,,OUTPATIENT,,,12.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505023,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505014,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505026,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505027,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505036,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505037,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505045,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505046,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505075,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505352,CDM,,OUTPATIENT,,,121.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,972,RC,7505367,CDM,,OUTPATIENT,,,121.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042012,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042021,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042022,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042024,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042025,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042035,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042036,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042044,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042045,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042075,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042080,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,350,RC,7042096,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73700,HCPCS,960,RC,7505024,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505025,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505043,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505044,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505073,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505074,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505350,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505351,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505355,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505356,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505357,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042019,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042020,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042023,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042042,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042043,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042073,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042074,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042078,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042079,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042084,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042085,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042086,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042089,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,350,RC,7042090,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505021,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,960,RC,7505022,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505360,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST MATERIAL,73701,HCPCS,972,RC,7505361,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,960,RC,7505042,CDM,,OUTPATIENT,,,143.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042041,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,972,RC,7505364,CDM,,OUTPATIENT,,,148.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST MATER,73702,HCPCS,350,RC,7042093,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,972,RC,7505377,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505109,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505108,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505105,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044067,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505394,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044062,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044024,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044023,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044020,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,960,RC,7505395,CDM,,OUTPATIENT,,,164.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73718,HCPCS,610,RC,7044066,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505141,CDM,,OUTPATIENT,,,259.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505140,CDM,,OUTPATIENT,,,259.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505107,CDM,,OUTPATIENT,,,259.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505106,CDM,,OUTPATIENT,,,259.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505104,CDM,,OUTPATIENT,,,259.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,960,RC,7505103,CDM,,OUTPATIENT,,,259.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044056,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044055,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044022,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044021,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044019,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING LOWER EXTREMITY OTH,73720,HCPCS,610,RC,7044018,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044039,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505092,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044038,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505093,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505119,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505120,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505123,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,960,RC,7505124,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044034,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044008,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044035,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73721,HCPCS,610,RC,7044007,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044032,CDM,,OUTPATIENT,,,1864.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505117,CDM,,OUTPATIENT,,,198.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,610,RC,7044033,CDM,,OUTPATIENT,,,1864.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73722,HCPCS,960,RC,7505118,CDM,,OUTPATIENT,,,198.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044030,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505122,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044037,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044036,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,610,RC,7044031,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505116,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505115,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ANY JOINT OF LOWER,73723,HCPCS,960,RC,7505121,CDM,,OUTPATIENT,,,260.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,7040000,CDM,,OUTPATIENT,,,265,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW,74018,HCPCS,960,RC,7505208,CDM,,OUTPATIENT,,,24.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,7040001,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 2 VIEWS,74019,HCPCS,960,RC,7505209,CDM,,OUTPATIENT,,,30.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS,74021,HCPCS,960,RC,7505210,CDM,,OUTPATIENT,,,33.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ABDOMEN 3 VIEWS,74021,HCPCS,320,RC,7040002,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COMPLETE ACUTE ABDOMEN SERIES INCLU,74022,HCPCS,972,RC,7505348,CDM,,OUTPATIENT,,,39.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042107,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,960,RC,7505007,CDM,,OUTPATIENT,,,145.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL,74150,HCPCS,352,RC,7042005,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042004,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,960,RC,7505006,CDM,,OUTPATIENT,,,155.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST MATERIAL(S),74160,HCPCS,352,RC,7042104,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,352,RC,7042003,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST MATERIAL FOL,74170,HCPCS,960,RC,7505005,CDM,,OUTPATIENT,,,169.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,960,RC,7505009,CDM,,OUTPATIENT,,,190.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN AND PELVIS WITH C,74174,HCPCS,350,RC,7042007,CDM,,OUTPATIENT,,,1437.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,960,RC,7505008,CDM,,OUTPATIENT,,,230.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN WITH CONTRAST MAT,74175,HCPCS,350,RC,7042006,CDM,,OUTPATIENT,,,883.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042002,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,960,RC,7505004,CDM,,OUTPATIENT,,,150.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74176,HCPCS,350,RC,7042110,CDM,,OUTPATIENT,,,1185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042001,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,350,RC,7042109,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITH CONTRAST MATER,74177,HCPCS,960,RC,7505003,CDM,,OUTPATIENT,,,159.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505076,CDM,,OUTPATIENT,,,175.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042000,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,960,RC,7505002,CDM,,OUTPATIENT,,,175.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY ABDOMEN AND PELVIS WITHOUT CONTRAST MA,74178,HCPCS,350,RC,7042076,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,960,RC,7505091,CDM,,OUTPATIENT,,,176.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74181,HCPCS,610,RC,7044006,CDM,,OUTPATIENT,,,1103.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,960,RC,7505090,CDM,,OUTPATIENT,,,209.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITH CONTR,74182,HCPCS,610,RC,7044005,CDM,,OUTPATIENT,,,1718.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,610,RC,7044004,CDM,,OUTPATIENT,,,1896,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE (EG PROTON) IMAGING ABDOMEN WITHOUT CO,74183,HCPCS,960,RC,7505089,CDM,,OUTPATIENT,,,271.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR ESOPHAGUS SINGLE W/ CONTRAST,74220,HCPCS,320,RC,7040021,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION ESOPHAGUS INCLUDING SCOUT CHEST RAD,74220,HCPCS,960,RC,7505231,CDM,,OUTPATIENT,,,53.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SWALLOWING FUNCTION WITH CINERADIOG,74230,HCPCS,960,RC,7505315,CDM,,OUTPATIENT,,,65.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7040104,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR UPPER GI DOUBLE CONTRAST STUDY,74246,HCPCS,320,RC,7040114,CDM,,OUTPATIENT,,,568.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION UPPER GASTROINTESTINAL TRACT INCLUD,74246,HCPCS,960,RC,7505325,CDM,,OUTPATIENT,,,82.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505301,CDM,,OUTPATIENT,,,55.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION SMALL INTESTINE INCLUDING MULTIPLE,74250,HCPCS,960,RC,7505300,CDM,,OUTPATIENT,,,55.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ GASTROGRAFIN,74250,HCPCS,320,RC,7040193,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR SMALL BOWEL W/ BARIUM,74250,HCPCS,320,RC,7040090,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION COLON INCLUDING SCOUT ABDOMINAL RAD,74270,HCPCS,960,RC,7505219,CDM,,OUTPATIENT,,,59.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR COLON BARIUM ENEMA W/ AIR COMPLETE,74270,HCPCS,320,RC,7040009,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLANGIOGRAPHY/PANCREATOGRAPHY NTRAOP RSI,74300,HCPCS,,,7040194,CDM,,OUTPATIENT,,,26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR CYSTOGRAM 3+ VWS,74430,HCPCS,320,RC,7040016,CDM,,OUTPATIENT,,,1207,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTOGRAPHY MINIMUM OF 3 VIEWS RADIOLOGICAL SUPERVISION AN,74430,HCPCS,960,RC,7505226,CDM,,OUTPATIENT,,,38.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART CALCIUM SCORING,75571,HCPCS,350,RC,8080001,CDM,,OUTPATIENT,,,304,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CT HEART + EVAL W/ CONTRAST,75572,HCPCS,350,RC,8080000,CDM,,OUTPATIENT,,,631,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7042008,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,960,RC,7505010,CDM,,OUTPATIENT,,,208.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA AND BILATE,75635,HCPCS,350,RC,7040214,CDM,,OUTPATIENT,,,631,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,320,RC,7040087,CDM,,OUTPATIENT,,,340.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING,75809,HCPCS,960,RC,7505297,CDM,,OUTPATIENT,,,55.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPY (SEPARATE PROCEDURE) UP TO 1 HOUR PHYSICIAN OR,76000,HCPCS,320,RC,760000,CDM,,OUTPATIENT,,,754,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PARATHYROID,76536,HCPCS,402,RC,765360,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US THYROID,76536,HCPCS,402,RC,7043050,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US HEAD/NECK SOFT TISSUE,76536,HCPCS,402,RC,7043030,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505203,CDM,,OUTPATIENT,,,70.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,7505180,CDM,,OUTPATIENT,,,70.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SOFT TISSUES OF HEAD AND NECK (EG THYROID PARA,76536,HCPCS,960,RC,76536,CDM,,OUTPATIENT,,,70.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND CHEST (INCLUDES MEDIASTINUM) REAL TIME WITH IMA,76604,HCPCS,960,RC,7505202,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE THORAX,76604,HCPCS,402,RC,7043049,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043013,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043014,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,402,RC,7043012,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505163,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505164,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76641,HCPCS,960,RC,7505162,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505167,CDM,,OUTPATIENT,,,80.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505166,CDM,,OUTPATIENT,,,80.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,960,RC,7505165,CDM,,OUTPATIENT,,,80.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043017,CDM,,OUTPATIENT,,,416,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043015,CDM,,OUTPATIENT,,,416,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND BREAST UNILATERAL REAL TIME WITH IMAGE DOCUMEN,76642,HCPCS,402,RC,7043016,CDM,,OUTPATIENT,,,416,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION C,76700,HCPCS,960,RC,7505153,CDM,,OUTPATIENT,,,96.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN COMPLETE,76700,HCPCS,402,RC,7043001,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SOFT TISSUE ABD/PEL,76705,HCPCS,402,RC,7043048,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,767700,CDM,,OUTPATIENT,,,70.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,402,RC,7043031,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505154,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505181,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505182,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505183,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION L,76705,HCPCS,960,RC,7505201,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ABDOMEN LIMITED,76705,HCPCS,402,RC,7043002,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US KIDNEY BILATERAL,76705,HCPCS,402,RC,767050,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AAA SCREENING,76706,HCPCS,402,RC,7043000,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND ABDOMINAL AORTA REAL TIME WITH IMAGE DOCUMENTAT,76706,HCPCS,960,RC,7505152,CDM,,OUTPATIENT,,,47.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76770,HCPCS,960,RC,7505199,CDM,,OUTPATIENT,,,87.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,7043046,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND RETROPERITONEAL (EG RENAL AORTA NODES) REAL,76775,HCPCS,960,RC,7505156,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AORTA,76775,HCPCS,402,RC,7043004,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB < 14 WEEKS,76801,HCPCS,402,RC,7043037,CDM,,OUTPATIENT,,,395.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76801,HCPCS,960,RC,7505190,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76805,HCPCS,960,RC,7505193,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,7043040,CDM,,OUTPATIENT,,,372.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB LIMITED,76815,HCPCS,402,RC,7043041,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76815,HCPCS,960,RC,7505194,CDM,,OUTPATIENT,,,78.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505192,CDM,,OUTPATIENT,,,106.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,960,RC,7505191,CDM,,OUTPATIENT,,,106.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76816,HCPCS,402,RC,7043039,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US OB FOLLOW UP,76816,HCPCS,402,RC,7043038,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,960,RC,7505195,CDM,,OUTPATIENT,,,90.64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PREGNANT UTERUS REAL TIME WITH IMAGE DOCUMENTAT,76817,HCPCS,402,RC,7043042,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76818,HCPCS,402,RC,7043022,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,960,RC,7505173,CDM,,OUTPATIENT,,,93.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING,76819,HCPCS,960,RC,7505172,CDM,,OUTPATIENT,,,90.64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING,76819,HCPCS,402,RC,7043023,CDM,,OUTPATIENT,,,567.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,960,RC,7505204,CDM,,OUTPATIENT,,,83.43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSVAGINAL,76830,HCPCS,402,RC,7043051,CDM,,OUTPATIENT,,,424.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76856,HCPCS,960,RC,7505196,CDM,,OUTPATIENT,,,82.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US PELVIC COMP,76856,HCPCS,402,RC,7043043,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,402,RC,7043044,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505197,CDM,,OUTPATIENT,,,45.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND PELVIC (NONOBSTETRIC) REAL TIME WITH IMAGE DOCU,76857,HCPCS,960,RC,7505158,CDM,,OUTPATIENT,,,45.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US BLADDER SCAN,76857,HCPCS,402,RC,7043007,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND SCROTUM AND CONTENTS,76870,HCPCS,960,RC,7505200,CDM,,OUTPATIENT,,,78.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US SCROTUM (CONTENTS),76870,HCPCS,402,RC,7043047,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND TRANSRECTAL,76872,HCPCS,360,RC,76872,CDM,,OUTPATIENT,,,334,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,402,RC,7043021,CDM,,OUTPATIENT,,,740.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND COMPLETE JOINT (IE JOINT SPACE AND PERI-ARTICUL,76881,HCPCS,960,RC,7505171,CDM,,OUTPATIENT,,,77.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505343,CDM,,OUTPATIENT,,,481,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505157,CDM,,OUTPATIENT,,,59.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505347,CDM,,OUTPATIENT,,,59.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,960,RC,7505346,CDM,,OUTPATIENT,,,59.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY ST,76882,HCPCS,972,RC,7505344,CDM,,OUTPATIENT,,,481,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043065,CDM,,OUTPATIENT,,,481.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US UPPER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043066,CDM,,OUTPATIENT,,,481.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE RIGHT,76882,HCPCS,402,RC,7043062,CDM,,OUTPATIENT,,,481.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE LEFT,76882,HCPCS,402,RC,7043061,CDM,,OUTPATIENT,,,481.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXTREMITY SOFT TISSUE BILATERAL,76882,HCPCS,402,RC,7505431,CDM,,OUTPATIENT,,,481,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US AXILLA,76882,HCPCS,402,RC,7043005,CDM,,OUTPATIENT,,,481.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,7043029,CDM,,OUTPATIENT,,,121,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,402,RC,65090,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND,76937,HCPCS,960,RC,7505179,CDM,,OUTPATIENT,,,29.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,450,RC,6230203,CDM,,OUTPATIENT,,,741,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505177,CDM,,OUTPATIENT,,,81.37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043028,CDM,,OUTPATIENT,,,740.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,972,RC,7505381,CDM,,OUTPATIENT,,,82.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043006,CDM,,OUTPATIENT,,,740.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043027,CDM,,OUTPATIENT,,,740.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,960,RC,7505178,CDM,,OUTPATIENT,,,81.37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPIRA,76942,HCPCS,402,RC,7043054,CDM,,OUTPATIENT,,,740.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACE,77001,HCPCS,320,RC,7040201,CDM,,OUTPATIENT,,,221,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR PORT PLACEMENT,77001,HCPCS,320,RC,7040198,CDM,,OUTPATIENT,,,221,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,960,RC,7505247,CDM,,OUTPATIENT,,,70.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,7040037,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPSY ASPI,77002,HCPCS,320,RC,77002,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR FLUORO GUIDANCE NEEDLE LOC SPINE,77003,HCPCS,320,RC,7040036,CDM,,OUTPATIENT,,,376.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER,77003,HCPCS,960,RC,7505246,CDM,,OUTPATIENT,,,76.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,350,RC,7042027,CDM,,OUTPATIENT,,,1437.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG BIOPS,77012,HCPCS,960,RC,7505029,CDM,,OUTPATIENT,,,138.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MRI BREAST WITHOUT ANDWITH CONTRAST W/CAD BILATERAL,77049,HCPCS,614,RC,7044059,CDM,,OUTPATIENT,,,1053.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNETIC RESONANCE IMAGING BREAST WITHOUT AND WITH CONTRAS,77049,HCPCS,972,RC,7505374,CDM,,OUTPATIENT,,,182.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,960,RC,77061,CDM,,OUTPATIENT,,,64.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,77061,HCPCS,401,RC,7047012,CDM,,OUTPATIENT,,,49.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,77062,HCPCS,401,RC,7047011,CDM,,OUTPATIENT,,,51.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,77063,CDM,,OUTPATIENT,,,66.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,960,RC,7505084,CDM,,OUTPATIENT,,,66.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,770630,CDM,,OUTPATIENT,,,51.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL (LIST SEPA,77063,HCPCS,403,RC,7047008,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047006,CDM,,OUTPATIENT,,,247.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505083,CDM,,OUTPATIENT,,,81.37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,7505082,CDM,,OUTPATIENT,,,81.37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,401,RC,770650,CDM,,OUTPATIENT,,,247,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77065,HCPCS,960,RC,77065,CDM,,OUTPATIENT,,,81.37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,77065,HCPCS,401,RC,7047007,CDM,,OUTPATIENT,,,247.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,77066,CDM,,OUTPATIENT,,,113.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047005,CDM,,OUTPATIENT,,,345.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,960,RC,7505081,CDM,,OUTPATIENT,,,112.27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIAGNOSTIC MAMMOGRAPHY INCLUDING COMPUTER-AIDED DETECTION (,77066,HCPCS,401,RC,7047009,CDM,,OUTPATIENT,,,345.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505372,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505371,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047004,CDM,,OUTPATIENT,,,258.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047003,CDM,,OUTPATIENT,,,258.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,403,RC,7047002,CDM,,OUTPATIENT,,,259,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING MAMMOGRAPHY BILATERAL (2-VIEW STUDY OF EACH BREAS,77067,HCPCS,972,RC,7505373,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE AGE STUDIES,77072,HCPCS,320,RC,7040010,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AGE STUDIES,77072,HCPCS,960,RC,7505220,CDM,,OUTPATIENT,,,26.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE LENGTH STUDIES (ORTHOROENTGENOGRAM SCANOGRAM),77073,HCPCS,960,RC,7505428,CDM,,OUTPATIENT,,,37.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR BONE LENGTH STUDIES SCANOGRAMS,77073,HCPCS,320,RC,7040192,CDM,,OUTPATIENT,,,243.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE (AXIAL AND,77075,HCPCS,960,RC,7505279,CDM,,OUTPATIENT,,,67.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XR OSSEOUS SURVEY COMPLETE,77075,HCPCS,320,RC,7040069,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,320,RC,7046000,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) BONE DENSITY STUDY,77080,HCPCS,960,RC,7505001,CDM,,OUTPATIENT,,,27.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,341,RC,7041015,CDM,,OUTPATIENT,,,534.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED),78013,HCPCS,960,RC,7505429,CDM,,OUTPATIENT,,,33.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID IMAGING (INCLUDING VASCULAR FLOW WHEN PERFORMED) W,78014,HCPCS,341,RC,7041012,CDM,,OUTPATIENT,,,770.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM THYROID UPTAKE SINGLE OR MULTI:REPORT,78014,HCPCS,960,RC,7505340,CDM,,OUTPATIENT,,,46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,960,RC,7505151,CDM,,OUTPATIENT,,,92.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION WHEN PERF,78070,HCPCS,341,RC,7041007,CDM,,OUTPATIENT,,,770.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,960,RC,7505396,CDM,,OUTPATIENT,,,48.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIVER IMAGING WITH VASCULAR FLOW,78202,HCPCS,343,RC,7041014,CDM,,OUTPATIENT,,,2477.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING,78226,HCPCS,341,RC,7041008,CDM,,OUTPATIENT,,,1235,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78226,HCPCS,972,RC,7505336,CDM,,OUTPATIENT,,,1235,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATOBILIARY SYSTEM IMAGING INCLUDING GALLBLADDER WHEN PRE,78227,HCPCS,960,RC,7505337,CDM,,OUTPATIENT,,,80.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,341,RC,7041009,CDM,,OUTPATIENT,,,1603,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM GASTRIC EMPTYING STUDY,78264,HCPCS,341,RC,7041003,CDM,,OUTPATIENT,,,1236,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC EMPTYING IMAGING STUDY (EG SOLID LIQUID OR BOTH),78264,HCPCS,960,RC,7505147,CDM,,OUTPATIENT,,,93.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,341,RC,7041004,CDM,,OUTPATIENT,,,987.77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,78278,HCPCS,960,RC,7505148,CDM,,OUTPATIENT,,,118.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE IMAGING WHOLE BODY INJECTION,78306,HCPCS,341,RC,7041000,CDM,,OUTPATIENT,,,1235,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING WHOLE BODY,78306,HCPCS,960,RC,7505144,CDM,,OUTPATIENT,,,101.97,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BONE AND/OR JOINT IMAGING 3 PHASE STUDY,78315,HCPCS,960,RC,7505146,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM BONE THREE PHASE STUDY INJECTION/SCAN,78315,HCPCS,341,RC,7041002,CDM,,OUTPATIENT,,,1235,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,,,7505339,CDM,,OUTPATIENT,,,2913,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78451,HCPCS,341,RC,7041011,CDM,,OUTPATIENT,,,2912.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,341,RC,7041010,CDM,,OUTPATIENT,,,4282,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOCARDIAL PERFUSION IMAGING TOMOGRAPHIC (SPECT) (INCLUDING,78452,HCPCS,960,RC,7505338,CDM,,OUTPATIENT,,,192.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,7041016,CDM,,OUTPATIENT,,,315.21,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY PERFUSION IMAGING PARTICULATE,78580,HCPCS,960,RC,8505432,CDM,,OUTPATIENT,,,86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,960,RC,7505150,CDM,,OUTPATIENT,,,93.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY VENTILATION (EG AEROSOL OR GAS) AND PERFUSION IMA,78582,HCPCS,341,RC,7041006,CDM,,OUTPATIENT,,,2356.64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX,78708,HCPCS,341,RC,7041005,CDM,,OUTPATIENT,,,1603,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION,78708,HCPCS,960,RC,7505149,CDM,,OUTPATIENT,,,142.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,341,RC,7041001,CDM,,OUTPATIENT,,,966.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR INFLAMMATORY PROC,78803,HCPCS,960,RC,7505145,CDM,,OUTPATIENT,,,117.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BASIC METABOLIC PANEL,80048,HCPCS,300,RC,7010046,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYTES,80051,HCPCS,300,RC,7010084,CDM,,OUTPATIENT,,,39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMP,80053,HCPCS,300,RC,7010072,CDM,,OUTPATIENT,,,58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL WITH DIRECT LDL,80061,HCPCS,300,RC,7010592,CDM,,OUTPATIENT,,,74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPID PANEL,80061,HCPCS,300,RC,7010122,CDM,,OUTPATIENT,,,74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENAL PNL,80069,HCPCS,300,RC,7010157,CDM,,OUTPATIENT,,,48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS PANEL (ACUTE) ALI,80074,HCPCS,300,RC,7010427,CDM,,OUTPATIENT,,,167,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACUTE HEPATITIS PANEL,80074,HCPCS,300,RC,7010697,CDM,,OUTPATIENT,,,80.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEP FNCT PNL,80076,HCPCS,300,RC,7010102,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCURONIDE URINE W/CONF ALI,80101,HCPCS,300,RC,7010399,CDM,,OUTPATIENT,,,97.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACETAMINOPHEN LEVEL,80143,HCPCS,300,RC,7010030,CDM,,OUTPATIENT,,,271.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADALIMUMAB ACTIVITY W/RFLX TO ANTIBODY ALI,80145,HCPCS,300,RC,7010690,CDM,,OUTPATIENT,,,60,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBAMAZEPINE TOTAL,80156,HCPCS,300,RC,7010062,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOZAPINE AND METABOLITES SERUM- ALI,80159,HCPCS,300,RC,10130779,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIGOXIN TOTAL,80162,HCPCS,300,RC,7010083,CDM,,OUTPATIENT,,,73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,80164,HCPCS,300,RC,7010188,CDM,,OUTPATIENT,,,74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GENTAMICIN,80170,HCPCS,300,RC,7010203,CDM,,OUTPATIENT,,,247.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE GABAPENTIN,80171,HCPCS,300,RC,7010785,CDM,,OUTPATIENT,,,105,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GABAPENTIN WHOLE BLOOD SERUM OR PLASMA,80171,HCPCS,300,RC,7010412,CDM,,OUTPATIENT,,,76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE LAMOTRIGINE,80175,HCPCS,300,RC,7010660,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80177,HCPCS,300,RC,7010460,CDM,,OUTPATIENT,,,103,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LITHIUM,80178,HCPCS,300,RC,7010123,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALICYLATE LEVEL,80179,HCPCS,300,RC,7010162,CDM,,OUTPATIENT,,,271.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENOBARBITAL LEVEL,80184,HCPCS,300,RC,7010139,CDM,,OUTPATIENT,,,271.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010401,CDM,,OUTPATIENT,,,46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENYTOIN TOTAL,80185,HCPCS,300,RC,7010584,CDM,,OUTPATIENT,,,46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TACROLIMUS,80197,HCPCS,300,RC,7010537,CDM,,OUTPATIENT,,,57.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOPIRAMATE,80201,HCPCS,300,RC,7010591,CDM,,OUTPATIENT,,,59.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREEN QUANTITATIVE TOPIRAMATE,80201,HCPCS,300,RC,7010828,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANCOMYCIN,80202,HCPCS,300,RC,7010189,CDM,,OUTPATIENT,,,74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZONISAMIDE LEVEL QUANTITATION - ALI,80203,HCPCS,300,RC,7010628,CDM,,OUTPATIENT,,,72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG ASSAY INFLIXIMAB,80230,HCPCS,300,RC,7010789,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010445,CDM,,OUTPATIENT,,,103,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010572,CDM,,OUTPATIENT,,,103,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
QUANTITATION OF THERAPEUTIC DRUG NOT ELSEWHERE SPECIFIED,80299,HCPCS,300,RC,7010461,CDM,,OUTPATIENT,,,103,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80305,HCPCS,300,RC,10315543,CDM,,OUTPATIENT,,,32.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80306,HCPCS,300,RC,7010186,CDM,,OUTPATIENT,,,67.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047167,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047162,CDM,,OUTPATIENT,,,116,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80307,HCPCS,300,RC,7010468,CDM,,OUTPATIENT,,,217,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,80307,HCPCS,300,RC,7047172,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL LEVEL,80320,HCPCS,300,RC,7010583,CDM,,OUTPATIENT,,,263.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOLS,80320,HCPCS,300,RC,7010538,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHANOL LEVEL W/ BAC,80320,HCPCS,300,RC,7010086,CDM,,OUTPATIENT,,,271.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7010670,CDM,,OUTPATIENT,,,75.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047173,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALKALOIDS NOT OTHERWISE SPECIFIED,80323,HCPCS,300,RC,7047174,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG TEST(S) PRESUMPTIVE ANY NUMBER OF DRUG CLASSES ANY N,80323,HCPCS,300,RC,7010664,CDM,,OUTPATIENT,,,27.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMPHETAMINES 3 OR 4,80325,HCPCS,300,RC,7010321,CDM,,OUTPATIENT,,,75.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,80335,HCPCS,300,RC,7041217,CDM,,OUTPATIENT,,,72.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BARBITURATES,80345,HCPCS,300,RC,7047168,CDM,,OUTPATIENT,,,92.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BARBITURATES,80345,HCPCS,300,RC,7010337,CDM,,OUTPATIENT,,,75.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BENZODIAZEPINES 1-12,80346,HCPCS,310,RC,7010708,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BENZODIAZEPINES 1-12,80346,HCPCS,300,RC,7010341,CDM,,OUTPATIENT,,,174.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPRENORPHINE,80348,HCPCS,300,RC,7010348,CDM,,OUTPATIENT,,,75.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING BUPRENORPHINE,80348,HCPCS,300,RC,7047176,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7047169,CDM,,OUTPATIENT,,,176,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANNABINOIDS NATURAL,80349,HCPCS,300,RC,7010368,CDM,,OUTPATIENT,,,116.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHADONE,80358,HCPCS,300,RC,7010671,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHADONE,80358,HCPCS,300,RC,7047155,CDM,,OUTPATIENT,,,82.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING METHYLPHENIDATE,80360,HCPCS,300,RC,7010856,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLPHENIDATE,80360,HCPCS,300,RC,7010471,CDM,,OUTPATIENT,,,157.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRAMADOL,80373,HCPCS,300,RC,7010549,CDM,,OUTPATIENT,,,189.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUG SCREENING TRAMADOL,80373,HCPCS,300,RC,7010855,CDM,,OUTPATIENT,,,122,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010185,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010649,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81001,HCPCS,300,RC,7010182,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81002,HCPCS,300,RC,81002,CDM,,OUTPATIENT,,,13.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN GL,81003,HCPCS,300,RC,7010183,CDM,,OUTPATIENT,,,12,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINALYSIS MICROSCOPIC ONLY,81015,HCPCS,300,RC,7010184,CDM,,OUTPATIENT,,,11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,81025,CDM,,OUTPATIENT,,,24.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010048,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,881025,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URINE PREGNANCY TEST BY VISUAL COLOR COMPARISON METHODS,81025,HCPCS,300,RC,7010187,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VOLUME MEASUREMENT FOR TIMED COLLECTION EACH,81050,HCPCS,300,RC,7010029,CDM,,OUTPATIENT,,,20,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,310,RC,7010338,CDM,,OUTPATIENT,,,290.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE,81206,HCPCS,300,RC,7010955,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE,81207,HCPCS,310,RC,7010339,CDM,,OUTPATIENT,,,507,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,81219,HCPCS,310,RC,7010963,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALR (CALRETICULIN) EXON 9 MUT PCR ALI,81219,HCPCS,310,RC,7010358,CDM,,OUTPATIENT,,,426,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CFTR GENE ANALYSIS COMMON VARIANTS,81220,HCPCS,310,RC,7010958,CDM,,OUTPATIENT,,,125,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYSTIC FIBROSIS (CFTR) 165 VARIANTS ALI,81220,HCPCS,310,RC,7010373,CDM,,OUTPATIENT,,,1948,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN F2 C.97G>A G20210A PATH ALI,81240,HCPCS,310,RC,7010503,CDM,,OUTPATIENT,,,230,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F2 (PROTHROMBIN COAGULATION FACTOR II) (EG HEREDITARY HYPE,81240,HCPCS,300,RC,8060013,CDM,,OUTPATIENT,,,98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT,81241,HCPCS,300,RC,7010733,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FACTOR V LEIDEN (F5) R506Q MUTATION ALI,81241,HCPCS,310,RC,7010400,CDM,,OUTPATIENT,,,257,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEXA GENE ANALYSIS COMMON VARIANTS,81255,HCPCS,300,RC,7010948,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TAY-SACHS DISEASE (HEXA) ALI,81255,HCPCS,310,RC,7010672,CDM,,OUTPATIENT,,,283,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS,81256,HCPCS,310,RC,7010781,CDM,,OUTPATIENT,,,146,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOCHROMATOSIS MUTATION ALI,81256,HCPCS,310,RC,7010430,CDM,,OUTPATIENT,,,229,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENEV617F MUTATIONQUANT ALI,81270,HCPCS,310,RC,7010457,CDM,,OUTPATIENT,,,321,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JAK2 GENE ANALYSIS P.VAL617PHE VARIANT,81270,HCPCS,310,RC,7010961,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METHYLENETETRAHYDROFOLATE RED ALI,81291,HCPCS,310,RC,7010479,CDM,,OUTPATIENT,,,229,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSATELLITE INSTABILITY ANALYSIS (EG HEREDITARY NON-POLY,81301,HCPCS,310,RC,881301,CDM,,OUTPATIENT,,,568.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10,81339,HCPCS,300,RC,7010964,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRB@ (T CELL ANTIGEN RECEPTOR BETA) (EG LEUKEMIA AND LYMPH,81340,HCPCS,300,RC,8060010,CDM,,OUTPATIENT,,,64.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UGT1A1 SEQUENCING ALI,81350,HCPCS,310,RC,881530,CDM,,OUTPATIENT,,,819,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA GLOBULIN HBB GENE SEQUENCING ALI,81364,HCPCS,300,RC,7010610,CDM,,OUTPATIENT,,,524,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 (EG >10 SNPS 2-10 M,81402,HCPCS,300,RC,7010474,CDM,,OUTPATIENT,,,526,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 (EG ANALYSIS OF SING,81403,HCPCS,300,RC,7010456,CDM,,OUTPATIENT,,,648,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEUROFIBROMATOSIS TYPE 1 SEQUENCING AND DELETION/DUPLICATION,81405,HCPCS,300,RC,7010635,CDM,,OUTPATIENT,,,20.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NON-INV PRENATAL TEST FTL ANEUPLOIDY ALI,81420,HCPCS,310,RC,881420,CDM,,OUTPATIENT,,,641.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL SOLID ORGAN OR HEM,81455,HCPCS,310,RC,881455,CDM,,OUTPATIENT,,,10219,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL,81511,HCPCS,300,RC,7010821,CDM,,OUTPATIENT,,,310.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR,81596,HCPCS,300,RC,7010970,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010110,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82009,HCPCS,300,RC,7010031,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KETONE BODY(S) (EG ACETONE ACETOACETIC ACID BETA-HYDROXYB,82010,HCPCS,300,RC,7010346,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADRENOCORTICOTROPIC HORMONE ACTH,82024,HCPCS,300,RC,7010257,CDM,,OUTPATIENT,,,135,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010033,CDM,,OUTPATIENT,,,27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010035,CDM,,OUTPATIENT,,,27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN SERUM PLASMA OR WHOLE BLOOD,82040,HCPCS,300,RC,7010036,CDM,,OUTPATIENT,,,27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010034,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010037,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010655,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010149,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,82042,HCPCS,300,RC,7010150,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010128,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010127,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,82043,HCPCS,300,RC,7010652,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALCOHOL (ETHANOL) BREATH,82075,HCPCS,300,RC,882072,CDM,,OUTPATIENT,,,39.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOLASE,82085,HCPCS,300,RC,7010280,CDM,,OUTPATIENT,,,37.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010281,CDM,,OUTPATIENT,,,143,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE,82088,HCPCS,300,RC,7010328,CDM,,OUTPATIENT,,,143,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALDOSTERONE/PLASMA RENIN RATIO QST,82088,HCPCS,300,RC,7044165,CDM,,OUTPATIENT,,,77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ALDOSTERONE,82088,HCPCS,300,RC,7044163,CDM,,OUTPATIENT,,,77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-1-ANTITRYPSIN TOTAL,82103,HCPCS,300,RC,7010253,CDM,,OUTPATIENT,,,74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,7010744,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA FETOPROTEIN TUMOR MARKER QST,82105,HCPCS,300,RC,8060018,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010258,CDM,,OUTPATIENT,,,92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010477,CDM,,OUTPATIENT,,,92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010478,CDM,,OUTPATIENT,,,92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALPHA-FETOPROTEIN (AFP) SERUM,82105,HCPCS,300,RC,7010606,CDM,,OUTPATIENT,,,92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMMONIA,82140,HCPCS,300,RC,7010040,CDM,,OUTPATIENT,,,80,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010041,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010044,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010043,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMYLASE,82150,HCPCS,300,RC,7010042,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN I - CONVERTING ENZYME (ACE),82164,HCPCS,300,RC,7010254,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANGIOTENSIN-1-CONVERTING ENZYME QST,82164,HCPCS,300,RC,7010921,CDM,,OUTPATIENT,,,69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARSENIC,82175,HCPCS,300,RC,7010442,CDM,,OUTPATIENT,,,81.37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASCORBIC ACID (VITAMIN C) BLOOD,82180,HCPCS,300,RC,7010566,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ASCORBIC ACID BLOOD,82180,HCPCS,300,RC,7010974,CDM,,OUTPATIENT,,,66.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA-2 MICROGLOBULIN,82232,HCPCS,300,RC,7010336,CDM,,OUTPATIENT,,,57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010051,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN TOTAL,82247,HCPCS,300,RC,7010052,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILIRUBIN DIRECT,82248,HCPCS,300,RC,7010050,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCULT BLOOD STOOL POCT,82270,HCPCS,300,RC,885018,CDM,,OUTPATIENT,,,13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,7010134,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82270,HCPCS,300,RC,822700,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIC OCCULT BLOOD,82271,HCPCS,300,RC,400624,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010133,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010132,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,6230155,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010130,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY PEROXIDASE ACTIVITY (EG GUAIAC) QUALITAT,82272,HCPCS,300,RC,7010131,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,882274,CDM,,OUTPATIENT,,,35.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD OCCULT BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOAS,82274,HCPCS,300,RC,7010104,CDM,,OUTPATIENT,,,56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 HYDROXY INCLUDES FRACTIONS IF PERFORMED,82306,HCPCS,300,RC,7010730,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010598,CDM,,OUTPATIENT,,,104,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010568,CDM,,OUTPATIENT,,,104,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 25 HYDROXY INCLUDES FRACTION(S) IF PERFORMED,82306,HCPCS,300,RC,7010191,CDM,,OUTPATIENT,,,104,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010355,CDM,,OUTPATIENT,,,94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCITONIN,82308,HCPCS,300,RC,7010826,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM TOTAL,82310,HCPCS,300,RC,7010060,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010455,CDM,,OUTPATIENT,,,48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM IONIZED,82330,HCPCS,300,RC,7010824,CDM,,OUTPATIENT,,,69.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010061,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULI RISK ASSESSMENT - ALI,82340,HCPCS,300,RC,8099,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCIUM URINE QUANTITATIVE TIMED SPECIMEN,82340,HCPCS,300,RC,7010059,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010356,CDM,,OUTPATIENT,,,51.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALCULUS INFRARED SPECTROSCOPY,82365,HCPCS,300,RC,7010819,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBON DIOXIDE (BICARBONATE),82374,HCPCS,300,RC,7010196,CDM,,OUTPATIENT,,,27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010198,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARBOXYHEMOGLOBIN QUANTITATIVE,82375,HCPCS,300,RC,7010197,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARCINOEMBRYONIC ANTIGEN (CEA),82378,HCPCS,300,RC,7010369,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010751,CDM,,OUTPATIENT,,,86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010361,CDM,,OUTPATIENT,,,88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CATECHOLAMINES FRACTIONATED,82384,HCPCS,300,RC,7010360,CDM,,OUTPATIENT,,,88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010371,CDM,,OUTPATIENT,,,39.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERULOPLASMIN,82390,HCPCS,300,RC,7010753,CDM,,OUTPATIENT,,,67.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010068,CDM,,OUTPATIENT,,,25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE BLOOD,82435,HCPCS,300,RC,7010066,CDM,,OUTPATIENT,,,25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010067,CDM,,OUTPATIENT,,,18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHLORIDE URINE,82436,HCPCS,300,RC,7010069,CDM,,OUTPATIENT,,,18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,7010642,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHOLESTEROL SERUM OR WHOLE BLOOD TOTAL,82465,HCPCS,300,RC,35104,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMIUM,82495,HCPCS,300,RC,7010386,CDM,,OUTPATIENT,,,44.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CHROMIUM,82495,HCPCS,300,RC,7010891,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CITRATE,82507,HCPCS,300,RC,7010698,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CITRATE,82507,HCPCS,300,RC,7010377,CDM,,OUTPATIENT,,,18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF COPPER,82525,HCPCS,300,RC,7010788,CDM,,OUTPATIENT,,,68.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COPPER,82525,HCPCS,300,RC,7010380,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010701,CDM,,OUTPATIENT,,,98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010620,CDM,,OUTPATIENT,,,58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL FREE,82530,HCPCS,300,RC,7010383,CDM,,OUTPATIENT,,,58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,8060017,CDM,,OUTPATIENT,,,69.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL QST,82533,HCPCS,300,RC,7010795,CDM,,OUTPATIENT,,,69.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010382,CDM,,OUTPATIENT,,,57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CORTISOL TOTAL,82533,HCPCS,300,RC,7010381,CDM,,OUTPATIENT,,,57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC,82542,HCPCS,300,RC,7010724,CDM,,OUTPATIENT,,,68.33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010502,CDM,,OUTPATIENT,,,133,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLUMN CHROMATOGRAPHY INCLUDES MASS SPECTROMETRY IF PERFOR,82542,HCPCS,300,RC,7010673,CDM,,OUTPATIENT,,,133,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010657,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) TOTAL,82550,HCPCS,300,RC,7010076,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010071,CDM,,OUTPATIENT,,,64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATINE KINASE (CK) (CPK) MB FRACTION ONLY,82553,HCPCS,300,RC,7010656,CDM,,OUTPATIENT,,,64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE BLOOD,82565,HCPCS,300,RC,7010077,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,882570,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010079,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010653,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE OTHER SOURCE,82570,HCPCS,300,RC,7010654,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CREATININE CLEARANCE,82575,HCPCS,300,RC,7010078,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE OR SEMI-QUANTITATIVE (EG CRYOCRIT,82595,HCPCS,300,RC,7010387,CDM,,OUTPATIENT,,,30.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE,82595,HCPCS,300,RC,7010792,CDM,,OUTPATIENT,,,63.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12),82607,HCPCS,300,RC,7010190,CDM,,OUTPATIENT,,,53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYANOCOBALAMIN (VITAMIN B-12) UNSATURATED BINDING CAPACITY,82608,HCPCS,300,RC,7010334,CDM,,OUTPATIENT,,,50,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE (DHEA),82626,HCPCS,300,RC,7010390,CDM,,OUTPATIENT,,,88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE,82626,HCPCS,300,RC,7010737,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S),82627,HCPCS,300,RC,7010389,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED,82652,HCPCS,300,RC,7010723,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN D 1 25 DIHYDROXY INCLUDES FRACTION(S) IF PERFORM,82652,HCPCS,300,RC,7010567,CDM,,OUTPATIENT,,,135,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EL-1 FECAL QUANTITATIVE,82653,HCPCS,300,RC,7010704,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENZYME ACTIVITY IN BLOOD CELLS CULTURED CELLS OR TISSUE N,82657,HCPCS,300,RC,882657,CDM,,OUTPATIENT,,,106.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ERYTHROPOIETIN,82668,HCPCS,300,RC,7010397,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESTRADIOL TOTAL,82670,HCPCS,300,RC,7010398,CDM,,OUTPATIENT,,,98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT/LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010857,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAT OR LIPIDS FECES QUALITATIVE,82705,HCPCS,300,RC,7010402,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FERRITIN,82728,HCPCS,300,RC,7010088,CDM,,OUTPATIENT,,,48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELIAC REFLEXIVE PANEL ALI,82734,HCPCS,300,RC,7010370,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID SERUM,82746,HCPCS,300,RC,7010089,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOLIC ACID RBC,82747,HCPCS,300,RC,7010507,CDM,,OUTPATIENT,,,62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGG) QST,82784,HCPCS,300,RC,7044095,CDM,,OUTPATIENT,,,66.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010633,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010452,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010450,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010447,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGA IGD IGG IGM EACH,82784,HCPCS,300,RC,7010446,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN G QST,82784,HCPCS,300,RC,7044088,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN M QST,82784,HCPCS,300,RC,7044089,CDM,,OUTPATIENT,,,64.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044101,CDM,,OUTPATIENT,,,64.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOGLOBULIN A QST,82784,HCPCS,300,RC,7044087,CDM,,OUTPATIENT,,,64.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010448,CDM,,OUTPATIENT,,,72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IGE,82785,HCPCS,300,RC,7010524,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAMMAGLOBULIN (IMMUNOGLOBULIN) IMMUNOGLOBULIN SUBCLASSES (E,82787,HCPCS,300,RC,7010451,CDM,,OUTPATIENT,,,44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010053,CDM,,OUTPATIENT,,,143,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010640,CDM,,OUTPATIENT,,,143,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010074,CDM,,OUTPATIENT,,,143,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010073,CDM,,OUTPATIENT,,,143,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010054,CDM,,OUTPATIENT,,,143,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,828030,CDM,,OUTPATIENT,,,143,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASES BLOOD ANY COMBINATION OF PH PCO2 PO2 CO2 HCO3 (I,82803,HCPCS,300,RC,7010055,CDM,,OUTPATIENT,,,143,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTRIN,82941,HCPCS,300,RC,7010414,CDM,,OUTPATIENT,,,45.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010095,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BODY FLUID OTHER THAN BLOOD,82945,HCPCS,300,RC,7010094,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,35120,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010646,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010097,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010096,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010644,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE QUANTITATIVE BLOOD (EXCEPT REAGENT STRIP),82947,HCPCS,300,RC,7010645,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE BLOOD REAGENT STRIP,82948,HCPCS,300,RC,82948,CDM,,OUTPATIENT,,,18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE POST GLUCOSE DOSE (INCLUDES GLUCOSE),82950,HCPCS,300,RC,7010093,CDM,,OUTPATIENT,,,40.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) QUANTITATIVE,82955,HCPCS,300,RC,7010411,CDM,,OUTPATIENT,,,48.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE,82955,HCPCS,300,RC,7010881,CDM,,OUTPATIENT,,,65.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010091,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTAMYLTRANSFERASE GAMMA (GGT),82977,HCPCS,300,RC,7010605,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF GLYCATED PROTEIN,82985,HCPCS,300,RC,7010930,CDM,,OUTPATIENT,,,125.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRUCTOSAMINE ALI,82985,HCPCS,300,RC,7010674,CDM,,OUTPATIENT,,,39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,8060011,CDM,,OUTPATIENT,,,65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN FOLLICLE STIMULATING HORMONE (FSH),83001,HCPCS,300,RC,7010408,CDM,,OUTPATIENT,,,65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN LUTEINIZING HORMONE (LH),83002,HCPCS,300,RC,7010463,CDM,,OUTPATIENT,,,65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAPTOGLOBIN QUANTITATIVE,83010,HCPCS,300,RC,7010418,CDM,,OUTPATIENT,,,44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,83013,HCPCS,300,RC,7010705,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
H. PYLORI UREA BREATH TEST ALI,83013,HCPCS,300,RC,7010675,CDM,,OUTPATIENT,,,60,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,7010379,CDM,,OUTPATIENT,,,121,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL (EG ARSENIC BARIUM BERYLLIUM BISMUTH ANTIMO,83018,HCPCS,300,RC,883018,CDM,,OUTPATIENT,,,121,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEAVY METAL QUANTIATIVE EACH NES,83018,HCPCS,300,RC,7010758,CDM,,OUTPATIENT,,,117.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN FRACTIONATION AND QUANTITATION CHROMATOGRAPHY (E,83021,HCPCS,300,RC,7010431,CDM,,OUTPATIENT,,,65.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED A1C,83036,HCPCS,300,RC,7010878,CDM,,OUTPATIENT,,,64.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN GLYCOSYLATED (A1C),83036,HCPCS,300,RC,7010101,CDM,,OUTPATIENT,,,53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOCYSTEINE,83090,HCPCS,300,RC,7010438,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYINDOLACETIC ACID 5-(HIAA),83497,HCPCS,300,RC,7010433,CDM,,OUTPATIENT,,,47.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA,83497,HCPCS,300,RC,7010722,CDM,,OUTPATIENT,,,67.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010483,CDM,,OUTPATIENT,,,95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF HYDROXYPROGESTERONE 17-D,83498,HCPCS,300,RC,7010728,CDM,,OUTPATIENT,,,95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010515,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010415,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010413,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010329,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010325,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010324,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010319,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010259,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP,83516,HCPCS,300,RC,7010712,CDM,,OUTPATIENT,,,74.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,11350041,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010614,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010554,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010526,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83516,HCPCS,300,RC,7010475,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY,83519,HCPCS,300,RC,7010757,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010251,CDM,,OUTPATIENT,,,101,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010255,CDM,,OUTPATIENT,,,101,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83519,HCPCS,300,RC,7010256,CDM,,OUTPATIENT,,,101,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010487,CDM,,OUTPATIENT,,,95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY,83520,HCPCS,300,RC,7010548,CDM,,OUTPATIENT,,,95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7010717,CDM,,OUTPATIENT,,,330,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY ANALYTE QUANTITATIVE NOS,83520,HCPCS,300,RC,7042186,CDM,,OUTPATIENT,,,95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-MULLERIAN HOROMONE ALI,83520,HCPCS,300,RC,7010676,CDM,,OUTPATIENT,,,136,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LIGHT CHAINS FREE RATIO QST,83521,HCPCS,300,RC,7044110,CDM,,OUTPATIENT,,,95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044108,CDM,,OUTPATIENT,,,95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN FREE SERUM QST,83521,HCPCS,300,RC,7044109,CDM,,OUTPATIENT,,,95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN QST,83525,HCPCS,300,RC,7010907,CDM,,OUTPATIENT,,,67,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INSULIN TOTAL,83525,HCPCS,300,RC,7010454,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON,83540,HCPCS,300,RC,7010108,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRON BINDING CAPACITY,83550,HCPCS,300,RC,7010109,CDM,,OUTPATIENT,,,48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010113,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010114,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010116,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE (LACTIC ACID),83605,HCPCS,300,RC,7010117,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010118,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTATE DEHYDROGENASE (LD) (LDH),83615,HCPCS,300,RC,7010112,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7010403,CDM,,OUTPATIENT,,,69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LACTOFERRIN FECAL QUALITATIVE,83630,HCPCS,300,RC,7999050,CDM,,OUTPATIENT,,,118.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD,83655,HCPCS,300,RC,7010677,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEAD BLOOD,83655,HCPCS,300,RC,7010911,CDM,,OUTPATIENT,,,219,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETL LEAD CAPILLARY,83655,HCPCS,300,RC,8060009,CDM,,OUTPATIENT,,,219,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010121,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPASE,83690,HCPCS,300,RC,7010120,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN (A),83695,HCPCS,300,RC,7010589,CDM,,OUTPATIENT,,,50,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010593,CDM,,OUTPATIENT,,,58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL,83721,HCPCS,300,RC,7010119,CDM,,OUTPATIENT,,,58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010125,CDM,,OUTPATIENT,,,37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010124,CDM,,OUTPATIENT,,,37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAGNESIUM,83735,HCPCS,300,RC,7010126,CDM,,OUTPATIENT,,,37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (EG MS MS/M,83789,HCPCS,300,RC,7010343,CDM,,OUTPATIENT,,,133,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010470,CDM,,OUTPATIENT,,,93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010706,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
METANEPHRINES,83835,HCPCS,300,RC,7010469,CDM,,OUTPATIENT,,,93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010678,CDM,,OUTPATIENT,,,48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010679,CDM,,OUTPATIENT,,,48.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYOGLOBIN,83874,HCPCS,300,RC,7010914,CDM,,OUTPATIENT,,,73.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATRIURETIC PEPTIDE,83880,HCPCS,300,RC,7010056,CDM,,OUTPATIENT,,,216,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044197,CDM,,OUTPATIENT,,,125.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KAPPA/LAMBDA LT CHAINS COMMENT QST,83883,HCPCS,300,RC,7044199,CDM,,OUTPATIENT,,,125.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LAMBDA LIGHT CHAIN TOTAL RANDOM UR QST,83883,HCPCS,300,RC,7044198,CDM,,OUTPATIENT,,,125.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010406,CDM,,OUTPATIENT,,,75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED,83883,HCPCS,300,RC,7010459,CDM,,OUTPATIENT,,,75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEOTIDASE 5'-,83915,HCPCS,300,RC,7010252,CDM,,OUTPATIENT,,,44.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID SINGLE QUANTITATIVE,83921,HCPCS,300,RC,7010473,CDM,,OUTPATIENT,,,74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORGANIC ACID 1 QUANTITATIVE,83921,HCPCS,300,RC,7010780,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010485,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY BLOOD,83930,HCPCS,300,RC,7010917,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOLALITY URINE,83935,HCPCS,300,RC,7010560,CDM,,OUTPATIENT,,,38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OSMOLALITY URINE,83935,HCPCS,300,RC,7010920,CDM,,OUTPATIENT,,,64.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OXALATE,83945,HCPCS,300,RC,7010557,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF OXALATE,83945,HCPCS,300,RC,7047153,CDM,,OUTPATIENT,,,127,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PARATHORMONE,83970,HCPCS,300,RC,7010783,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010501,CDM,,OUTPATIENT,,,144,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARATHORMONE (PARATHYROID HORMONE),83970,HCPCS,300,RC,7010500,CDM,,OUTPATIENT,,,144,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010138,CDM,,OUTPATIENT,,,20,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010135,CDM,,OUTPATIENT,,,20,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010136,CDM,,OUTPATIENT,,,20,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PH BODY FLUID NOT OTHERWISE SPECIFIED,83986,HCPCS,300,RC,7010137,CDM,,OUTPATIENT,,,20,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHENCYCLIDINE (PCP),83992,HCPCS,300,RC,7010489,CDM,,OUTPATIENT,,,105.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHENCYCLIDINE,83992,HCPCS,300,RC,7047170,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010726,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CALPROTECTIN FECAL,83993,HCPCS,300,RC,7010357,CDM,,OUTPATIENT,,,108,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010816,CDM,,OUTPATIENT,,,62.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010038,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE,84075,HCPCS,300,RC,7010294,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHATASE ALKALINE ISOENZYMES,84080,HCPCS,300,RC,7010347,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE),84100,HCPCS,300,RC,7010140,CDM,,OUTPATIENT,,,26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHOSPHORUS INORGANIC (PHOSPHATE) URINE,84105,HCPCS,300,RC,7010141,CDM,,OUTPATIENT,,,18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PORPHYRINS FECAL - ALI,84126,HCPCS,300,RC,7010612,CDM,,OUTPATIENT,,,162,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,35140,CDM,,OUTPATIENT,,,26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010143,CDM,,OUTPATIENT,,,26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM SERUM PLASMA OR WHOLE BLOOD,84132,HCPCS,300,RC,7010145,CDM,,OUTPATIENT,,,26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010144,CDM,,OUTPATIENT,,,26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POTASSIUM URINE,84133,HCPCS,300,RC,7010146,CDM,,OUTPATIENT,,,26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010486,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREALBUMIN,84134,HCPCS,300,RC,7010874,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE,84144,HCPCS,300,RC,7010495,CDM,,OUTPATIENT,,,73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROGESTERONE QST,84144,HCPCS,300,RC,7010923,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010719,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROCALCITONIN (PCT),84145,HCPCS,300,RC,7010494,CDM,,OUTPATIENT,,,180.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLACTIN,84146,HCPCS,300,RC,7010496,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010153,CDM,,OUTPATIENT,,,101,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL,84153,HCPCS,300,RC,7010586,CDM,,OUTPATIENT,,,101,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL,84153,HCPCS,300,RC,7010893,CDM,,OUTPATIENT,,,65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE SPECIFIC ANTIGEN (PSA) FREE,84154,HCPCS,300,RC,7010499,CDM,,OUTPATIENT,,,64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY SERUM PLASMA OR WH,84155,HCPCS,300,RC,7010151,CDM,,OUTPATIENT,,,13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010580,CDM,,OUTPATIENT,,,20,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY URINE,84156,HCPCS,300,RC,7010344,CDM,,OUTPATIENT,,,20,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010147,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN TOTAL EXCEPT BY REFRACTOMETRY OTHER SOURCE (EG S,84157,HCPCS,300,RC,7010148,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A),84163,HCPCS,300,RC,7010476,CDM,,OUTPATIENT,,,53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010491,CDM,,OUTPATIENT,,,38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION SER,84165,HCPCS,300,RC,7010490,CDM,,OUTPATIENT,,,38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010559,CDM,,OUTPATIENT,,,62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTEIN ELECTROPHORETIC FRACTIONATION AND QUANTITATION OTH,84166,HCPCS,300,RC,7010558,CDM,,OUTPATIENT,,,62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF PYRIDOXAL PHOSPHATE,84207,HCPCS,300,RC,7010965,CDM,,OUTPATIENT,,,75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PYRIDOXAL PHOSPHATE (VITAMIN B-6),84207,HCPCS,300,RC,7010565,CDM,,OUTPATIENT,,,98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RECEPTOR ASSAY NON-ENDOCRINE (SPECIFY RECEPTOR),84238,HCPCS,300,RC,7010533,CDM,,OUTPATIENT,,,106.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7044164,CDM,,OUTPATIENT,,,77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RENIN,84244,HCPCS,300,RC,7010513,CDM,,OUTPATIENT,,,77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RENIN,84244,HCPCS,300,RC,7010727,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF RIBOFLAVIN-VITAMIN B-2,84252,HCPCS,300,RC,7010791,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBOFLAVIN (VITAMIN B-2),84252,HCPCS,300,RC,7010564,CDM,,OUTPATIENT,,,111,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SELENIUM,84255,HCPCS,300,RC,7010662,CDM,,OUTPATIENT,,,79.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELENIUM ALI,84255,HCPCS,300,RC,7010661,CDM,,OUTPATIENT,,,120,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SEROTONIN,84260,HCPCS,300,RC,7010817,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEROTONIN,84260,HCPCS,300,RC,7010680,CDM,,OUTPATIENT,,,108,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEX HORMONE BINDING GLOBULIN (SHBG),84270,HCPCS,300,RC,7010523,CDM,,OUTPATIENT,,,76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010166,CDM,,OUTPATIENT,,,26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM SERUM PLASMA OR WHOLE BLOOD,84295,HCPCS,300,RC,7010168,CDM,,OUTPATIENT,,,26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010169,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SODIUM URINE,84300,HCPCS,300,RC,7010167,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOMATOMEDIN,84305,HCPCS,300,RC,7010449,CDM,,OUTPATIENT,,,74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF SOMATOMEDIN,84305,HCPCS,300,RC,7010721,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUGARS (MONO- DI- AND OLIGOSACCHARIDES) SINGLE QUALITATIV,84376,HCPCS,300,RC,7010534,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FREE TESTOSTERONE ALI,84402,HCPCS,300,RC,7010410,CDM,,OUTPATIENT,,,89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE FREE,84402,HCPCS,300,RC,7010541,CDM,,OUTPATIENT,,,89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010716,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOTAL TESTOSTERONE ALI,84403,HCPCS,300,RC,7010407,CDM,,OUTPATIENT,,,90,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010542,CDM,,OUTPATIENT,,,90,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE TOTAL,84403,HCPCS,300,RC,7010539,CDM,,OUTPATIENT,,,90,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TESTOSTERONE BIOAVAILABLE DIRECT MEASUREMENT (EG DIFFEREN,84410,HCPCS,300,RC,7010540,CDM,,OUTPATIENT,,,179,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THIAMINE-VITAMIN B-1,84425,HCPCS,300,RC,7010885,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010681,CDM,,OUTPATIENT,,,74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THIAMINE (VITAMIN B-1),84425,HCPCS,300,RC,7010563,CDM,,OUTPATIENT,,,74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010545,CDM,,OUTPATIENT,,,88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF THYROGLOBULIN,84432,HCPCS,300,RC,7010947,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN,84432,HCPCS,300,RC,7010609,CDM,,OUTPATIENT,,,88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE TOTAL,84436,HCPCS,300,RC,7010536,CDM,,OUTPATIENT,,,29.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROXINE FREE,84439,HCPCS,300,RC,7010090,CDM,,OUTPATIENT,,,50,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010175,CDM,,OUTPATIENT,,,92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING HORMONE (TSH),84443,HCPCS,300,RC,7010171,CDM,,OUTPATIENT,,,92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS (TSI),84445,HCPCS,300,RC,7010551,CDM,,OUTPATIENT,,,178,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID STIMULATING IMMUNE GLOBULINS TSI,84445,HCPCS,300,RC,7010823,CDM,,OUTPATIENT,,,88.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TOCOPHEROL ALPHA VITAMIN E,84446,HCPCS,300,RC,7010981,CDM,,OUTPATIENT,,,71.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOCOPHEROL ALPHA (VITAMIN E),84446,HCPCS,300,RC,7010569,CDM,,OUTPATIENT,,,50,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010405,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010045,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ASPARTATE AMINO (AST) (SGOT),84450,HCPCS,300,RC,7010607,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERASE ALANINE AMINO (ALT) (SGPT),84460,HCPCS,300,RC,7010039,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSFERRIN,84466,HCPCS,300,RC,7010550,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010173,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIGLYCERIDES,84478,HCPCS,300,RC,7010172,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING,84479,HCPCS,300,RC,7010555,CDM,,OUTPATIENT,,,33.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 TOTAL (TT-3),84480,HCPCS,300,RC,7010535,CDM,,OUTPATIENT,,,50,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T3 TOTAL QST,84480,HCPCS,300,RC,7010936,CDM,,OUTPATIENT,,,65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010409,CDM,,OUTPATIENT,,,59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF TRIIODOTHYRONINE T3 FREE,84481,HCPCS,300,RC,7010756,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRIIODOTHYRONINE T3 REVERSE,84482,HCPCS,300,RC,7010518,CDM,,OUTPATIENT,,,55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010174,CDM,,OUTPATIENT,,,69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TROPONIN QUANTITATIVE,84484,HCPCS,300,RC,7010648,CDM,,OUTPATIENT,,,69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN QUANTITATIVE,84520,HCPCS,300,RC,7010058,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010176,CDM,,OUTPATIENT,,,31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UREA NITROGEN URINE,84540,HCPCS,300,RC,7010177,CDM,,OUTPATIENT,,,31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010179,CDM,,OUTPATIENT,,,25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID BLOOD,84550,HCPCS,300,RC,7010178,CDM,,OUTPATIENT,,,25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010181,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
URIC ACID OTHER SOURCE,84560,HCPCS,300,RC,7010180,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VANILLYLMANDELIC ACID URINE,84585,HCPCS,300,RC,7047157,CDM,,OUTPATIENT,,,69.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VANILLYLMANDELIC ACID (VMA) URINE,84585,HCPCS,300,RC,7010570,CDM,,OUTPATIENT,,,49.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN A,84590,HCPCS,300,RC,7010960,CDM,,OUTPATIENT,,,71.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN A,84590,HCPCS,300,RC,7010562,CDM,,OUTPATIENT,,,45.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047175,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7047151,CDM,,OUTPATIENT,,,124.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAMIN NOT OTHERWISE SPECIFIED,84591,HCPCS,300,RC,7010482,CDM,,OUTPATIENT,,,143.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ASSAY OF ZINC,84630,HCPCS,300,RC,7010982,CDM,,OUTPATIENT,,,69.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ZINC,84630,HCPCS,300,RC,7010574,CDM,,OUTPATIENT,,,41.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-PEPTIDE,84681,HCPCS,300,RC,7010384,CDM,,OUTPATIENT,,,73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010049,CDM,,OUTPATIENT,,,83,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUANTITATIVE,84702,HCPCS,300,RC,7010342,CDM,,OUTPATIENT,,,83,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC QUANTITATIVE,84702,HCPCS,300,RC,7010932,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010165,CDM,,OUTPATIENT,,,41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GONADOTROPIN CHORIONIC (HCG) QUALITATIVE,84703,HCPCS,300,RC,7010047,CDM,,OUTPATIENT,,,41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED CHEMISTRY PROCEDURE,84999,HCPCS,300,RC,884999,CDM,,OUTPATIENT,,,54.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010650,CDM,,OUTPATIENT,,,13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMATOCRIT (HCT),85014,HCPCS,300,RC,7010099,CDM,,OUTPATIENT,,,13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010641,CDM,,OUTPATIENT,,,13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010651,CDM,,OUTPATIENT,,,13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT HEMOGLOBIN (HGB),85018,HCPCS,300,RC,7010100,CDM,,OUTPATIENT,,,13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) AUTOMATED (HGB HCT RBC WBC A,85025,HCPCS,300,RC,7010064,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/DIFF AUTOMATED,85025,HCPCS,300,RC,7010063,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT COMPLETE (CBC) W/O DIFF AUTOMATED,85027,HCPCS,300,RC,7010065,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE MANUAL,85044,HCPCS,300,RC,7010594,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010208,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010514,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT RETICULOCYTE AUTOMATED,85045,HCPCS,300,RC,7010926,CDM,,OUTPATIENT,,,62.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010193,CDM,,OUTPATIENT,,,14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT LEUKOCYTE (WBC) AUTOMATED,85048,HCPCS,300,RC,7010192,CDM,,OUTPATIENT,,,14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD COUNT PLATELET AUTOMATED,85049,HCPCS,300,RC,7010142,CDM,,OUTPATIENT,,,25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR II PROTHROMBIN SPECIFIC,85210,HCPCS,301,RC,7010682,CDM,,OUTPATIENT,,,51.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VON WILLEBRAND WORKUP,85240,HCPCS,300,RC,7010571,CDM,,OUTPATIENT,,,44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING FACTOR IX PTC/CHRISTMAS,85250,HCPCS,300,RC,7010953,CDM,,OUTPATIENT,,,125,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS ANTITHROMBIN III ACT,85300,HCPCS,300,RC,7010332,CDM,,OUTPATIENT,,,41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010497,CDM,,OUTPATIENT,,,55.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN C ACTIVITY,85303,HCPCS,300,RC,7010731,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS PROTEIN S FREE,85306,HCPCS,300,RC,7010732,CDM,,OUTPATIENT,,,75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLOTTING INHIBITORS OR ANTICOAGULANTS PROTEIN S FREE,85306,HCPCS,300,RC,7010498,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRIN DEGRADATION PRODUCTS D-DIMER QUANTITATIVE,85379,HCPCS,300,RC,7010082,CDM,,OUTPATIENT,,,56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY CLAUSS QST,85384,HCPCS,300,RC,7010868,CDM,,OUTPATIENT,,,70,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FIBRINOGEN ACTIVITY,85384,HCPCS,300,RC,7010404,CDM,,OUTPATIENT,,,53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEMOGLOBIN OR RBCS FETAL FOR FETOMATERNAL HEMORRHAGE ROSE,85461,HCPCS,300,RC,7010028,CDM,,OUTPATIENT,,,50.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPARIN ASSAY,85520,HCPCS,300,RC,7010636,CDM,,OUTPATIENT,,,59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSMOTIC FRAGILITY RBC UNINCUBATED,85555,HCPCS,300,RC,7010611,CDM,,OUTPATIENT,,,167,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010107,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010154,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010453,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010600,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROTHROMBIN TIME,85610,HCPCS,300,RC,7010942,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010391,CDM,,OUTPATIENT,,,46.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME DILUTED,85613,HCPCS,300,RC,7010715,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUSSELL VIPER VENOM TIME (INCLUDES VENOM) DILUTED,85613,HCPCS,300,RC,7010601,CDM,,OUTPATIENT,,,46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REPTILASE TEST,85635,HCPCS,300,RC,7010850,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEDIMENTATION RATE ERYTHROCYTE NON-AUTOMATED,85651,HCPCS,300,RC,7010085,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBIN TIME PLASMA,85670,HCPCS,300,RC,7010543,CDM,,OUTPATIENT,,,54.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010032,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010504,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010522,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010585,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010599,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010602,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,85730,HCPCS,300,RC,7010925,CDM,,OUTPATIENT,,,63.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,85730,HCPCS,300,RC,7010155,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,885999,CDM,,OUTPATIENT,,,29.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE,85999,HCPCS,300,RC,7010199,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010293,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010295,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010296,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010297,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010299,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010300,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010301,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010303,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010304,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010305,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010306,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010307,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010308,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010309,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010310,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010311,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010312,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010314,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010315,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010316,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010317,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010318,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010512,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010615,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010616,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY INHALANTS NORTHEAST COMP ALI,86003,HCPCS,300,RC,886003,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND (F20) IGE QST,86003,HCPCS,300,RC,7047098,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALMOND CLASS QST,86003,HCPCS,300,RC,7047099,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT (F202) IGE QST,86003,HCPCS,300,RC,7047096,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CASHEW NUT CLASS QST,86003,HCPCS,300,RC,7047097,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CAT EPI. AND DANDER IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010269,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM (F207) IGE QST,86003,HCPCS,300,RC,7047040,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLAM CLASS QST,86003,HCPCS,300,RC,7047041,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH (F3) IGE QST,86003,HCPCS,300,RC,7044141,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CODFISH CLASS QST,86003,HCPCS,300,RC,7044142,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH,86003,HCPCS,300,RC,7010747,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,450,RC,8067,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010260,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010261,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010262,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010263,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010264,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010265,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010266,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010267,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010268,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010270,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010271,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010272,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010273,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010274,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010275,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010276,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010277,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010278,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010279,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010282,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010283,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010284,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010285,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010286,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010287,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010288,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010290,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010291,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE CRU,86003,HCPCS,300,RC,7010292,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN (F79) IGE QST,86003,HCPCS,300,RC,7010813,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLUTEN ALLERGEN ALI,86003,HCPCS,300,RC,7010289,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE (F1) IGE QST,86003,HCPCS,300,RC,7044133,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EGG WHITE CLASS QST,86003,HCPCS,300,RC,7044134,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT (F18) IGE QST,86003,HCPCS,300,RC,7047104,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRAZIL NUT CLASS QST,86003,HCPCS,300,RC,7047105,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT (F17) IGE QST,86003,HCPCS,300,RC,7047094,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAZELNUT CLASS QST,86003,HCPCS,300,RC,7047095,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT (F13) IGE QST,86003,HCPCS,300,RC,7047090,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT CLASS QST,86003,HCPCS,300,RC,7047091,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PEANUT IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010302,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT (F201) IGE QST,86003,HCPCS,300,RC,7047100,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PECAN NUT CLASS QST,86003,HCPCS,300,RC,7047101,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO (F203) IGE QST,86003,HCPCS,300,RC,7047102,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PISTACHIO CLASS QST,86003,HCPCS,300,RC,7047103,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON (F41) IGE QST,86003,HCPCS,300,RC,7044159,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SALMON CLASS QST,86003,HCPCS,300,RC,7044160,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP (F338) IGE QST,86003,HCPCS,300,RC,7044149,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCALLOP CLASS QST,86003,HCPCS,300,RC,7044150,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED (F10) IGE QST,86003,HCPCS,300,RC,7044151,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SESAME SEED CLASS QST,86003,HCPCS,300,RC,7044152,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7044147,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP (F24) IGE QST,86003,HCPCS,300,RC,7047038,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SHRIMP CLASS QST,86003,HCPCS,300,RC,7044148,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN (F14) IGE QST,86003,HCPCS,300,RC,7044145,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SOYBEAN CLASS QST,86003,HCPCS,300,RC,7044146,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STRAWBERRY ALLERGEN ALI,86003,HCPCS,300,RC,7010313,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK (F2) IGE QST,86003,HCPCS,300,RC,7044143,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COW S MILK CLASS QST,86003,HCPCS,300,RC,7044144,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB (F23) IGE QST,86003,HCPCS,300,RC,7047042,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRAB CLASS QST,86003,HCPCS,300,RC,7047043,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MILK IGE ALLERGEN ALI,86003,HCPCS,300,RC,7010298,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIXED NUTS ALLERGEN PANEL ALI,86003,HCPCS,300,RC,7010472,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80) IGE CLASS,86003,HCPCS,300,RC,7047045,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOBSTER (F80)IGE QST,86003,HCPCS,300,RC,7047044,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT (RF345) IGE QST,86003,HCPCS,300,RC,7047106,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MACADAMIA NUT CLASS QST,86003,HCPCS,300,RC,7047107,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT (F256) IGE QST,86003,HCPCS,300,RC,7047092,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WALNUT CLASS QST,86003,HCPCS,300,RC,7047093,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT (F4) IGE QST,86003,HCPCS,300,RC,7044137,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEAT CLASS QST,86003,HCPCS,300,RC,7044138,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA (F40) IGE QST,86003,HCPCS,300,RC,7044161,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUNA CLASS QST,86003,HCPCS,300,RC,7044162,CDM,,OUTPATIENT,,,65.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 3 (F424) QST,86008,HCPCS,300,RC,7044269,CDM,,OUTPATIENT,,,88.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 1 (F422) QST,86008,HCPCS,300,RC,7044267,CDM,,OUTPATIENT,,,88.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 2 (F423) QST,86008,HCPCS,300,RC,7044268,CDM,,OUTPATIENT,,,88.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 6 (F447) QST,86008,HCPCS,300,RC,7044270,CDM,,OUTPATIENT,,,88.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 8 (F352) QST,86008,HCPCS,300,RC,7044271,CDM,,OUTPATIENT,,,88.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ARA H 9 (F427) QST,86008,HCPCS,300,RC,7044272,CDM,,OUTPATIENT,,,88.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGEN SPECIFIC IGE QUANTITATIVE OR SEMIQUANTITATIVE REC,86008,HCPCS,300,RC,86008,CDM,,OUTPATIENT,,,56.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ACTIN ANTIBODY EACH,86015,HCPCS,300,RC,7047160,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES (ANA),86038,HCPCS,300,RC,7010322,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTINUCLEAR ANTIBODIES ANA,86038,HCPCS,300,RC,7010739,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTISTREPTOLYSIN 0 TITER,86060,HCPCS,300,RC,7010330,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN,86140,HCPCS,300,RC,7010075,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY (HSCRP),86141,HCPCS,300,RC,7010385,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C-REACTIVE PROTEIN HIGH SENSITIVITY,86141,HCPCS,300,RC,7010693,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BETA 2 GLYCOPROTEIN I ANTIBODY EACH,86146,HCPCS,300,RC,7010335,CDM,,OUTPATIENT,,,89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGG)AB QST,86146,HCPCS,300,RC,7042203,CDM,,OUTPATIENT,,,70,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B2 GLYCOPROTEIN I (IGM)AB QST,86146,HCPCS,300,RC,7042204,CDM,,OUTPATIENT,,,70,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGM) QST,86147,HCPCS,300,RC,7047069,CDM,,OUTPATIENT,,,64.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN AB (IGG) QST,86147,HCPCS,300,RC,7047068,CDM,,OUTPATIENT,,,64.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY EACH IG CLASS,86147,HCPCS,300,RC,7010359,CDM,,OUTPATIENT,,,89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY,86148,HCPCS,300,RC,7010604,CDM,,OUTPATIENT,,,38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86156,HCPCS,300,RC,886156,CDM,,OUTPATIENT,,,71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010349,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010350,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT ANTIGEN EACH COMPONENT,86160,HCPCS,300,RC,7010782,CDM,,OUTPATIENT,,,72.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL (CH50) ALI,86162,HCPCS,300,RC,7010622,CDM,,OUTPATIENT,,,71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPLEMENT TOTAL HEMOLYTIC,86162,HCPCS,300,RC,7010913,CDM,,OUTPATIENT,,,67.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE ANTIBODY,86200,HCPCS,300,RC,7010700,CDM,,OUTPATIENT,,,70,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY,86200,HCPCS,300,RC,7010365,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY NATIVE OR DOUBLE STRAN,86225,HCPCS,300,RC,7010392,CDM,,OUTPATIENT,,,48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86231 = ENDOMYSIAL AB IGA WITH REFLEX ALI,86231,HCPCS,300,RC,7010395,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMA EACH IG CLASS,86231,HCPCS,300,RC,7010711,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCLERODERMA SCL-70 (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010521,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCL-70 ANTIBODY QST,86235,HCPCS,300,RC,7010877,CDM,,OUTPATIENT,,,71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-A) QST,86235,HCPCS,300,RC,7044217,CDM,,OUTPATIENT,,,76.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SJOGREN S ANTIBODY (SS-B) QST,86235,HCPCS,300,RC,7044218,CDM,,OUTPATIENT,,,76.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM ANTIBODY QST,86235,HCPCS,300,RC,7044200,CDM,,OUTPATIENT,,,76.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SM/RNP ANTIBODY QST,86235,HCPCS,300,RC,7044201,CDM,,OUTPATIENT,,,76.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSA 52 (RO) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010529,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SSB (LA) (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010530,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RIBONUCLEIC PROTEIN (ENA) ABIGG ALI,86235,HCPCS,300,RC,7010516,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY TO ANY METHOD (EG NR,86235,HCPCS,300,RC,7010603,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,86235,HCPCS,300,RC,7010852,CDM,,OUTPATIENT,,,76.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTRACTABLE NUCLEAR AG ABS ALI,86235,HCPCS,300,RC,7010396,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMITH (ENA) ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010527,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
JO-1 ANTIBODYIGG ALI,86235,HCPCS,300,RC,7010327,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010323,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARIETAL CELL ANTIBODY IGG ALI,86255,HCPCS,300,RC,7010488,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PARANEOPLASTIC AB W/REFLEX ALI,86255,HCPCS,300,RC,12429730,CDM,,OUTPATIENT,,,83,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY SCREEN EACH ANTIB,86255,HCPCS,300,RC,7010493,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTI MOG IGG SERUM W/ REFLEX ALI,86255,HCPCS,300,RC,12147876,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GLIADIN (DEAMIDATED) AB (IGA) QST,86258,HCPCS,300,RC,7044096,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010352,CDM,,OUTPATIENT,,,73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 15-3 (27.29),86300,HCPCS,300,RC,7010354,CDM,,OUTPATIENT,,,73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3,86300,HCPCS,300,RC,7010815,CDM,,OUTPATIENT,,,69.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 19-9,86301,HCPCS,300,RC,7010353,CDM,,OUTPATIENT,,,73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010814,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE CA 125,86304,HCPCS,300,RC,7010351,CDM,,OUTPATIENT,,,73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010621,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HETEROPHILE ANTIBODIES SCREENING,86308,HCPCS,300,RC,7010129,CDM,,OUTPATIENT,,,28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOASSAY FOR TUMOR ANTIGEN OTHER ANTIGEN QUANTITATIVE (,86316,HCPCS,300,RC,7010374,CDM,,OUTPATIENT,,,73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86331 (3) NMMC,86331,HCPCS,300,RC,7010608,CDM,,OUTPATIENT,,,11.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010696,CDM,,OUTPATIENT,,,71.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS SERUM,86334,HCPCS,300,RC,7010525,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS,86335,HCPCS,300,RC,7010695,CDM,,OUTPATIENT,,,71.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFIXATION ELECTROPHORESIS OTHER FLUIDS WITH CONCENTRAT,86335,HCPCS,300,RC,7010556,CDM,,OUTPATIENT,,,103,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010444,CDM,,OUTPATIENT,,,57.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRINSIC FACTOR ANTIBODIES,86340,HCPCS,300,RC,7010908,CDM,,OUTPATIENT,,,69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010443,CDM,,OUTPATIENT,,,130,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010759,CDM,,OUTPATIENT,,,67.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ISLET CELL ANTIBODY,86341,HCPCS,300,RC,7010326,CDM,,OUTPATIENT,,,130,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NATURAL KILLER (NK) CELLS TOTAL COUNT,86357,HCPCS,310,RC,886357,CDM,,OUTPATIENT,,,41.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS TOTAL COUNT,86359,HCPCS,310,RC,886359,CDM,,OUTPATIENT,,,132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
T CELLS ABSOLUTE CD4 AND CD8 COUNT INCLUDING RATIO,86360,HCPCS,300,RC,886360,CDM,,OUTPATIENT,,,164,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86364 = TISSUE TRANSGLUTAMINASE AB IGA ALI,86364,HCPCS,300,RC,7010553,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010464,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010544,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES EACH,86376,HCPCS,310,RC,7010709,CDM,,OUTPATIENT,,,67.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICROSOMAL ANTIBODIES (EG THYROID OR LIVER-KIDNEY) EACH,86376,HCPCS,300,RC,7010320,CDM,,OUTPATIENT,,,51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MITOCHONDRIAL ANTIBODY EACH,86381,HCPCS,300,RC,7010822,CDM,,OUTPATIENT,,,66.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RABIES ANTIBODY ALI,86382,HCPCS,300,RC,7010613,CDM,,OUTPATIENT,,,91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QST,86431,HCPCS,300,RC,7010865,CDM,,OUTPATIENT,,,62.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,12147873,CDM,,OUTPATIENT,,,31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RHEUMATOID FACTOR QUANTITATIVE,86431,HCPCS,300,RC,7010506,CDM,,OUTPATIENT,,,30.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86480,HCPCS,300,RC,7010683,CDM,,OUTPATIENT,,,217,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON,86480,HCPCS,300,RC,7010797,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7047166,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULOSIS TEST CELL MEDIATED IMMUNITY ANTIGEN RESPONSE M,86481,HCPCS,300,RC,7010552,CDM,,OUTPATIENT,,,350,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP,86481,HCPCS,300,RC,7010799,CDM,,OUTPATIENT,,,73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TUBERCULIN PURIFIED PROTEIN DERIVATIVE,86580,HCPCS,636,RC,589103,CDM,,OUTPATIENT,,,26.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SKIN TEST TUBERCULOSIS INTRADERMAL,86580,HCPCS,300,RC,86580,CDM,,OUTPATIENT,,,12,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,86592,HCPCS,300,RC,7010787,CDM,,OUTPATIENT,,,62.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUALITATIVE (EG VDR,86592,HCPCS,300,RC,7010517,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BARTONELLA,86611,HCPCS,300,RC,7010362,CDM,,OUTPATIENT,,,40.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGG) SCREEN QST,86611,HCPCS,300,RC,7044265,CDM,,OUTPATIENT,,,80,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
B. HENSELAE AB (IGM) SCREEN QST,86611,HCPCS,300,RC,7044266,CDM,,OUTPATIENT,,,80,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
93 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044128,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGG) BLOT QST,86617,HCPCS,300,RC,7044118,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LYME DISEASE AB(IGM) BLOT QST,86617,HCPCS,300,RC,7044129,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY T,86617,HCPCS,300,RC,7010466,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
66 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044127,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
58 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044126,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
45 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044125,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044132,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
41 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044124,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044131,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
39 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044123,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044122,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
28 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044121,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGM) BAND QST,86617,HCPCS,300,RC,7044130,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
18 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044119,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
23 KD (IGG) BAND QST,86617,HCPCS,300,RC,7044120,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY BORRELIA BURGDORFERI LYME DISEASE,86618,HCPCS,300,RC,7010916,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BORRELIA BURGDORFERI (LYME) ABS WITH REF ALI,86618,HCPCS,300,RC,7010465,CDM,,OUTPATIENT,,,40.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV,86644,HCPCS,300,RC,7044178,CDM,,OUTPATIENT,,,70,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS (CMV),86644,HCPCS,300,RC,7010378,CDM,,OUTPATIENT,,,50,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY CYTOMEGALOVIRUS CMV IGM,86645,HCPCS,300,RC,7044179,CDM,,OUTPATIENT,,,70,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044086,CDM,,OUTPATIENT,,,69.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA,86664,HCPCS,300,RC,7044085,CDM,,OUTPATIENT,,,69.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044084,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR (EB) VIRUS VIRAL CAPSID (VCA),86665,HCPCS,300,RC,7010393,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA,86665,HCPCS,300,RC,7044083,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY EHRLICHIA,86666,HCPCS,300,RC,7010432,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS 1/2 ABS WITH REFLEX ALI,86696,HCPCS,300,RC,7010441,CDM,,OUTPATIENT,,,32.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1,86701,HCPCS,300,RC,7010435,CDM,,OUTPATIENT,,,31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY HIV-1 AND HIV-2 SINGLE RESULT,86703,HCPCS,300,RC,7010103,CDM,,OUTPATIENT,,,75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010428,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY HBCAB TOTAL,86704,HCPCS,300,RC,7010882,CDM,,OUTPATIENT,,,66.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) TOTAL,86704,HCPCS,300,RC,7010419,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B CORE ANTIBODY (HBCAB) IGM ANTIBODY,86705,HCPCS,300,RC,7010420,CDM,,OUTPATIENT,,,41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010421,CDM,,OUTPATIENT,,,38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURF ANTIBODY HBSAB,86706,HCPCS,300,RC,7010880,CDM,,OUTPATIENT,,,64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIBODY (HBSAB),86706,HCPCS,300,RC,7010575,CDM,,OUTPATIENT,,,38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE ANTIBODY HBEAB,86707,HCPCS,300,RC,7010906,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIBODY ALI,86707,HCPCS,300,RC,7010684,CDM,,OUTPATIENT,,,44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY HAAB,86708,HCPCS,300,RC,7010887,CDM,,OUTPATIENT,,,67.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB),86708,HCPCS,300,RC,7010416,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A ANTIBODY (HAAB) IGM ANTIBODY,86709,HCPCS,300,RC,7010417,CDM,,OUTPATIENT,,,61.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS ANTIBODY HAAB IGM ANTIBODY,86709,HCPCS,300,RC,7010889,CDM,,OUTPATIENT,,,66.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010794,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MUMPS VIRUS ANTIBODY IGG ALI,86735,HCPCS,300,RC,7010480,CDM,,OUTPATIENT,,,39.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY MUMPS,86735,HCPCS,300,RC,7010481,CDM,,OUTPATIENT,,,46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGM) QST,86738,HCPCS,300,RC,7044248,CDM,,OUTPATIENT,,,67.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE ANTIBODY (IGG) QST,86738,HCPCS,300,RC,7044247,CDM,,OUTPATIENT,,,67.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MYCOPLASMA PNEUMONIAE AB IGG/IGM ALI,86738,HCPCS,300,RC,7010625,CDM,,OUTPATIENT,,,48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGM QST,86753,HCPCS,300,RC,7044263,CDM,,OUTPATIENT,,,89.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI AB IGG QST,86753,HCPCS,300,RC,7044262,CDM,,OUTPATIENT,,,89.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BABESIA MICROTI ABS IGG/IGM ALI,86753,HCPCS,300,RC,7010626,CDM,,OUTPATIENT,,,60,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RESPIRATORY SYNCYTIAL VIRUS,86756,HCPCS,300,RC,7010160,CDM,,OUTPATIENT,,,261.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
86757 NMMC,86757,HCPCS,300,RC,7010624,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGM) QST,86762,HCPCS,300,RC,7044170,CDM,,OUTPATIENT,,,65.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBELLA,86762,HCPCS,300,RC,7010928,CDM,,OUTPATIENT,,,64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY (IGG) DIAGNOSTIC QST,86762,HCPCS,300,RC,7044169,CDM,,OUTPATIENT,,,65.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RUBELLA ANTIBODY IGG ALI,86762,HCPCS,300,RC,7010519,CDM,,OUTPATIENT,,,30.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY RUBEOLA,86765,HCPCS,300,RC,7010984,CDM,,OUTPATIENT,,,63.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES (RUBEOLA) ANTIBODY IGG ALI,86765,HCPCS,300,RC,7010520,CDM,,OUTPATIENT,,,40.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 ANTIBODY TOTAL ALI,86769,HCPCS,302,RC,7010587,CDM,,OUTPATIENT,,,147,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TOXOPLASMA,86777,HCPCS,300,RC,7010547,CDM,,OUTPATIENT,,,66.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010685,CDM,,OUTPATIENT,,,46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY TREPONEMA PALLIDUM,86780,HCPCS,300,RC,7010861,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010702,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VARICELLA-ZOSTER,86787,HCPCS,300,RC,7010573,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VARICELLA-ZOSTER VIRUS ANTIBODY IGG ALI,86787,HCPCS,300,RC,7010561,CDM,,OUTPATIENT,,,41.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED,86790,HCPCS,300,RC,7010755,CDM,,OUTPATIENT,,,69.27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPESVIRUS 6 ANTIBODY IGG ALI,86790,HCPCS,300,RC,7010627,CDM,,OUTPATIENT,,,126,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,7010333,CDM,,OUTPATIENT,,,56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THYROGLOBULIN ANTIBODY,86800,HCPCS,300,RC,8060012,CDM,,OUTPATIENT,,,66.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010424,CDM,,OUTPATIENT,,,50,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010933,CDM,,OUTPATIENT,,,65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C ANTIBODY,86803,HCPCS,300,RC,7010576,CDM,,OUTPATIENT,,,50,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HLA B27 ALI,86812,HCPCS,302,RC,7010437,CDM,,OUTPATIENT,,,90,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY SCREEN RBC,86850,HCPCS,300,RC,886850,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010004,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010003,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,35005,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE,86850,HCPCS,300,RC,7010002,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BB ELUTION,86860,HCPCS,300,RC,886860,CDM,,OUTPATIENT,,,111,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIBODY ID RBC,86870,HCPCS,300,RC,886870,CDM,,OUTPATIENT,,,100,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIBODY IDENTIFICATION RBC ANTIBODIES EACH PANEL FOR EACH,86870,HCPCS,300,RC,7010001,CDM,,OUTPATIENT,,,954,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY ANTIHUMAN GLOBULIN,86880,HCPCS,300,RC,886880,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010011,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010013,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010014,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANTIHUMAN GLOBULIN TEST (COOMBS TEST) DIRECT EACH ANTISERU,86880,HCPCS,300,RC,7010012,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COOMBS TEST INDRECT,86885,HCPCS,300,RC,886885,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010000,CDM,,OUTPATIENT,,,16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010010,CDM,,OUTPATIENT,,,16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,300,RC,7010581,CDM,,OUTPATIENT,,,16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ABO,86900,HCPCS,300,RC,7010691,CDM,,OUTPATIENT,,,38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ABO,86900,HCPCS,,,886900,CDM,,OUTPATIENT,,,38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,,,886901,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010582,CDM,,OUTPATIENT,,,16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC RH (D),86901,HCPCS,300,RC,7010669,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH(D),86901,HCPCS,300,RC,7010692,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING ANTIGEN,86902,HCPCS,300,RC,886902,CDM,,OUTPATIENT,,,124,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010007,CDM,,OUTPATIENT,,,87.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010006,CDM,,OUTPATIENT,,,87.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOOD TYPING SEROLOGIC ANTIGEN TESTING OF DONOR BLOOD USIN,86902,HCPCS,300,RC,7010005,CDM,,OUTPATIENT,,,87.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RBC ANTI.,86905,HCPCS,300,RC,886905,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY BLOOD TYPING RH PHENOTYPE,86906,HCPCS,300,RC,886906,CDM,,OUTPATIENT,,,71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY CAMPATIBILITY TESTING IM,86920,HCPCS,300,RC,886920,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT IMMEDIATE SPIN TECHNIQUE,86920,HCPCS,300,RC,7010008,CDM,,OUTPATIENT,,,489,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTING IN,86921,HCPCS,300,RC,886921,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COMPATIBILITY TESTIN AN,86922,HCPCS,300,RC,886922,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMPATIBILITY TEST EACH UNIT ANTIGLOBULIN TECHNIQUE,86922,HCPCS,300,RC,7010009,CDM,,OUTPATIENT,,,489,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA THAWING EACH UNIT,86927,HCPCS,300,RC,7010250,CDM,,OUTPATIENT,,,489,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT RBC ANTIBODY,86970,HCPCS,300,RC,886970,CDM,,OUTPATIENT,,,69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY COLD AGGLUTININ SCREEN,86971,HCPCS,300,RC,886971,CDM,,OUTPATIENT,,,41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY DILUTION OF SERUM,86976,HCPCS,300,RC,886976,CDM,,OUTPATIENT,,,79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY PRETREAT SERUM DIFF.,86978,HCPCS,300,RC,886978,CDM,,OUTPATIENT,,,71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC WITH ISOLATION AND PRESU,87040,HCPCS,306,RC,7010210,CDM,,OUTPATIENT,,,57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,87040,HCPCS,306,RC,7999003,CDM,,OUTPATIENT,,,67.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ISOL SALMONELLASHIGELL,87045,HCPCS,306,RC,7999047,CDM,,OUTPATIENT,,,67.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT STOOL AEROBIC ADDL PATHOGENSID EA,87046,HCPCS,306,RC,7999046,CDM,,OUTPATIENT,,,76.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010226,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010229,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010241,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999029,CDM,,OUTPATIENT,,,69.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999001,CDM,,OUTPATIENT,,,69.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999011,CDM,,OUTPATIENT,,,69.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999021,CDM,,OUTPATIENT,,,69.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999022,CDM,,OUTPATIENT,,,69.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999024,CDM,,OUTPATIENT,,,69.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010224,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010220,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,87070,HCPCS,306,RC,7999027,CDM,,OUTPATIENT,,,69.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010217,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY OTHER SOURCE EXCEPT URINE BLOOD OR,87070,HCPCS,306,RC,7010219,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010232,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010230,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010238,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010214,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010215,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010216,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010218,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010222,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010213,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010228,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010225,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010212,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010211,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE EXCEPT BLOOD ANAEROBIC WITH,87075,HCPCS,306,RC,7010209,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISOID,87075,HCPCS,306,RC,7999014,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,87076,HCPCS,300,RC,7999016,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL ANAEROBIC ISOLATE ADDITIONAL METHODS RE,87076,HCPCS,300,RC,870760,CDM,,OUTPATIENT,,,44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,87077,HCPCS,306,RC,7999004,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010237,CDM,,OUTPATIENT,,,44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,306,RC,7010242,CDM,,OUTPATIENT,,,44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL AEROBIC ISOLATE ADDITIONAL METHODS REQU,87077,HCPCS,300,RC,7010363,CDM,,OUTPATIENT,,,44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999045,CDM,,OUTPATIENT,,,72.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,300,RC,7999041,CDM,,OUTPATIENT,,,72.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,87081,HCPCS,306,RC,7999023,CDM,,OUTPATIENT,,,72.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010227,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010223,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE PRESUMPTIVE PATHOGENIC ORGANISMS SCREENING ONLY,87081,HCPCS,306,RC,7010221,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRUCELLA SCREEN,87081,HCPCS,306,RC,8060015,CDM,,OUTPATIENT,,,75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREEN FOR S. AUREUS,87081,HCPCS,306,RC,8060016,CDM,,OUTPATIENT,,,99.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,87086,HCPCS,300,RC,7999012,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BCT ISOLPRSMPTV ID ISOLATE EA URINE,87088,HCPCS,306,RC,7999013,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE BACTERIAL WITH ISOLATION AND PRESUMPTIVE IDENTIFIC,87088,HCPCS,306,RC,7010231,CDM,,OUTPATIENT,,,44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL,87101,HCPCS,306,RC,7999030,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010372,CDM,,OUTPATIENT,,,46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FUNGI (MOLD OR YEAST) ISOLATION WITH PRESUMPTIVE I,87102,HCPCS,300,RC,7010364,CDM,,OUTPATIENT,,,46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD,87102,HCPCS,300,RC,7999025,CDM,,OUTPATIENT,,,71.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD,87103,HCPCS,306,RC,7999036,CDM,,OUTPATIENT,,,68.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IMMUNOLOGIC METHOD OTHER THAN IMMUNOFLUORE,87147,HCPCS,306,RC,7010240,CDM,,OUTPATIENT,,,18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010205,CDM,,OUTPATIENT,,,70,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CULTURE TYPING IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA),87149,HCPCS,300,RC,7010204,CDM,,OUTPATIENT,,,70,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOMOGENIZATION TISSUE FOR CULTURE,87176,HCPCS,306,RC,7010239,CDM,,OUTPATIENT,,,12.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OVA AND PARASITES CONC AND PERM SMEAR MB QST,87177,HCPCS,306,RC,7999043,CDM,,OUTPATIENT,,,62.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7999042,CDM,,OUTPATIENT,,,88.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT DISK METHOD PE,87184,HCPCS,300,RC,7010686,CDM,,OUTPATIENT,,,40.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,87184,HCPCS,300,RC,7047165,CDM,,OUTPATIENT,,,88.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,300,RC,7010637,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT ENZYME DETECTIO,87185,HCPCS,306,RC,7010236,CDM,,OUTPATIENT,,,40.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010233,CDM,,OUTPATIENT,,,48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUSCEPTIBILITY STUDIES ANTIMICROBIAL AGENT MICRODILUTION O,87186,HCPCS,306,RC,7010234,CDM,,OUTPATIENT,,,48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999002,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999015,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,7010235,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,300,RC,7010098,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,87205,HCPCS,300,RC,7999028,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION GRAM OR GIEMSA ST,87205,HCPCS,306,RC,8060014,CDM,,OUTPATIENT,,,67.33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC FLUORESCENT/AFS BCT FNGI PARASIT,87206,HCPCS,300,RC,7999026,CDM,,OUTPATIENT,,,62.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC SPEC STAIN BODIES/PARASITS,87207,HCPCS,300,RC,7010929,CDM,,OUTPATIENT,,,78.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMR PRIM SRC CPLX SPEC STAIN OVAPARASITS,87209,HCPCS,306,RC,7999044,CDM,,OUTPATIENT,,,64.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010194,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010111,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,7010195,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMEAR PRIMARY SOURCE WITH INTERPRETATION WET MOUNT FOR INF,87210,HCPCS,300,RC,887210,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS ISOLATION INOCULATION OF EMBRYONATED EGGS OR SMALL A,87250,HCPCS,300,RC,887250,CDM,,OUTPATIENT,,,191.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT,87252,HCPCS,300,RC,7010922,CDM,,OUTPATIENT,,,76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87305,HCPCS,300,RC,7010331,CDM,,OUTPATIENT,,,24.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFFICILE/EPI (GENEXPERT),87324,HCPCS,300,RC,7010596,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87328 = CRYPTOSPORIDIUM ANTIGEN,87328,HCPCS,300,RC,13056565,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GIARDIA/CRYPTO AG,87329,HCPCS,300,RC,7010092,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HELICOBACTER PYLORI AGFECAL BY EIA ALI,87338,HCPCS,300,RC,7010505,CDM,,OUTPATIENT,,,76.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010879,CDM,,OUTPATIENT,,,63.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS B SURFACE ANTIGEN,87340,HCPCS,300,RC,7010577,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B SURFACE ANTIGEN ALI,87340,HCPCS,300,RC,7010422,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HEPATITIS BE ANTIGEN,87350,HCPCS,300,RC,7010904,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS BE VIRUS ANTIGEN ALI,87350,HCPCS,300,RC,7010687,CDM,,OUTPATIENT,,,40,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA HIV-1 AG W/HIV-1 HIV-2 ANTBDY SINGLE,87389,HCPCS,300,RC,7010956,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87426,HCPCS,301,RC,87426,CDM,,OUTPATIENT,,,92.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA SHIGA-LIKE TOXIN,87427,HCPCS,306,RC,7999049,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7999048,CDM,,OUTPATIENT,,,67.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IAAD IA MULT STEP METHOD NOS EACH ORGANISM,87449,HCPCS,300,RC,7010720,CDM,,OUTPATIENT,,,67.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEGIONELLA PNEUMOPHILA ANTIGEN UR ALI,87449,HCPCS,300,RC,7010462,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
C DIFF ANTIGEN,87449,HCPCS,300,RC,7010663,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE,87449,HCPCS,300,RC,7010340,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) BOR,87476,HCPCS,300,RC,7010467,CDM,,OUTPATIENT,,,133.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
87491 CT/NG (GENEXPERT),87491,HCPCS,300,RC,7010532,CDM,,OUTPATIENT,,,22.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CHL,87491,HCPCS,300,RC,7010388,CDM,,OUTPATIENT,,,123,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STD PANEL C. TRACH N. GONORR MOLEC ALI,87491,HCPCS,300,RC,7010531,CDM,,OUTPATIENT,,,123,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) CLO,87493,HCPCS,300,RC,887493,CDM,,OUTPATIENT,,,241,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CMV QUANTITATIVE ALI,87497,HCPCS,300,RC,887497,CDM,,OUTPATIENT,,,150,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ENTERIC PATHOGENS TEST (VERIGENE),87506,HCPCS,300,RC,7010597,CDM,,OUTPATIENT,,,920,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HBV BY QUANTITATIVE NAAT ALI,87517,HCPCS,300,RC,7010423,CDM,,OUTPATIENT,,,150,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS B VIRUS QUANTIFICATION,87517,HCPCS,300,RC,7010931,CDM,,OUTPATIENT,,,130,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HEPATITIS C QUANT REVERSE TRANSCRIPTION,87522,HCPCS,300,RC,7010786,CDM,,OUTPATIENT,,,129,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C VIRUS (HCV) QUANTITATION ALI,87522,HCPCS,300,RC,7010425,CDM,,OUTPATIENT,,,196.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HCV QUANTITATION RFLX ALI,87522,HCPCS,300,RC,7010426,CDM,,OUTPATIENT,,,196.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 1 DNA QST,87529,HCPCS,300,RC,7044167,CDM,,OUTPATIENT,,,64.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV 2 DNA QST,87529,HCPCS,300,RC,7044168,CDM,,OUTPATIENT,,,64.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR - CSF ALI,87529,HCPCS,300,RC,7010440,CDM,,OUTPATIENT,,,123,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HERPES SIMPLEX VIRUS PCR ALI,87529,HCPCS,300,RC,7010439,CDM,,OUTPATIENT,,,123,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-1 DNA QN PCR QST,87530,HCPCS,300,RC,7042125,CDM,,OUTPATIENT,,,105,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HSV-2 DNA QN PCR QST,87530,HCPCS,300,RC,7044276,CDM,,OUTPATIENT,,,105,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HIV-1 AMPLIFIED PROBE REVERSE TRANSCRPJ,87535,HCPCS,300,RC,7010957,CDM,,OUTPATIENT,,,150,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HIV-1 RNA QUANT BY PCR ALI,87536,HCPCS,300,RC,7010436,CDM,,OUTPATIENT,,,298,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,87591,HCPCS,300,RC,7010578,CDM,,OUTPATIENT,,,22.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MONKEYPOX VIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044250,CDM,,OUTPATIENT,,,135,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ORTHOPOXVIRUS DNA QL PCR QST,87593,HCPCS,300,RC,7044249,CDM,,OUTPATIENT,,,135,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES,87624,HCPCS,300,RC,887624,CDM,,OUTPATIENT,,,123,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFLUENZA A AND B MOLECULAR,87631,HCPCS,306,RC,7010106,CDM,,OUTPATIENT,,,499,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010647,CDM,,OUTPATIENT,,,499,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLU (VERIGENE),87631,HCPCS,306,RC,7010159,CDM,,OUTPATIENT,,,499,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) RES,87631,HCPCS,300,RC,7010161,CDM,,OUTPATIENT,,,499,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RESPIRATORY PATHOGENS FLEX (VERIGENE),87633,HCPCS,306,RC,7010158,CDM,,OUTPATIENT,,,1459,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COVID-19 TESTING SEND OUT,87635,HCPCS,306,RC,7010590,CDM,,OUTPATIENT,,,180,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010588,CDM,,OUTPATIENT,,,180,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) SEV,87635,HCPCS,300,RC,7010643,CDM,,OUTPATIENT,,,180,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SARS-COV-2 (COVID-19)/FLU/RSV (GENEXPERT),87637,HCPCS,300,RC,7010639,CDM,,OUTPATIENT,,,285,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP B STREP (ARIES),87653,HCPCS,300,RC,7010206,CDM,,OUTPATIENT,,,123,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) TRI,87661,HCPCS,300,RC,7010579,CDM,,OUTPATIENT,,,123,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010458,CDM,,OUTPATIENT,,,193,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010623,CDM,,OUTPATIENT,,,193,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010688,CDM,,OUTPATIENT,,,193,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,12147868,CDM,,OUTPATIENT,,,193,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047164,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87798,HCPCS,300,RC,7010546,CDM,,OUTPATIENT,,,193,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,87798,HCPCS,300,RC,7047158,CDM,,OUTPATIENT,,,308.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) NOT,87799,HCPCS,300,RC,7010394,CDM,,OUTPATIENT,,,190.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA NOS QUANTIFICATION EACH ORGANISM,87799,HCPCS,300,RC,7010694,CDM,,OUTPATIENT,,,160,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ,87801,HCPCS,300,RC,7010714,CDM,,OUTPATIENT,,,185,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87804,HCPCS,300,RC,7010105,CDM,,OUTPATIENT,,,58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STREP A RAPID,87880,HCPCS,300,RC,7010170,CDM,,OUTPATIENT,,,58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87880,HCPCS,960,RC,7010666,CDM,,OUTPATIENT,,,27.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010528,CDM,,OUTPATIENT,,,88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIREC,87899,HCPCS,300,RC,7010345,CDM,,OUTPATIENT,,,88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR R,87901,HCPCS,300,RC,7010434,CDM,,OUTPATIENT,,,741.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS C GENOTYPING BY PCR ALI,87902,HCPCS,300,RC,7010429,CDM,,OUTPATIENT,,,901,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NFCT AGNT GENOTYP NUCLEIC ACID HEPATITIS C VIRUS,87902,HCPCS,300,RC,7010851,CDM,,OUTPATIENT,,,65.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CONCENTRATION TECHNIQUE SMEARS AND INTERPRET,88108,HCPCS,310,RC,888108,CDM,,OUTPATIENT,,,111.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CYTOPATHOLOGY CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) C,88142,HCPCS,300,RC,188142,CDM,,OUTPATIENT,,,71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BILL ONLY FNA CYTOPATH EVAL,88173,HCPCS,311,RC,888173,CDM,,OUTPATIENT,,,163,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,88182,HCPCS,310,RC,888182,CDM,,OUTPATIENT,,,106.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,7010595,CDM,,OUTPATIENT,,,954,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88184,HCPCS,311,RC,888184,CDM,,OUTPATIENT,,,954,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLOW CYTOMETRY CELL SURFACE CYTOPLASMIC OR NUCLEAR MARKER,88185,HCPCS,311,RC,888185,CDM,,OUTPATIENT,,,115.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS LYMPHOCYTE,88230,HCPCS,311,RC,7010375,CDM,,OUTPATIENT,,,408,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TISSUE CULTURE FOR NEOPLASTIC DISORDERS BONE MARROW BLOOD,88237,HCPCS,310,RC,38556,CDM,,OUTPATIENT,,,314.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES BASELINE SISTER,88245,HCPCS,300,RC,7010376,CDM,,OUTPATIENT,,,356.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS,88264,HCPCS,310,RC,401070,CDM,,OUTPATIENT,,,982.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHROMOSOME ANALYSIS ADDITIONAL KARYOTYPES EACH STUDY,88280,HCPCS,310,RC,401071,CDM,,OUTPATIENT,,,170.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL I - SURGICAL PATHOLOGY GROSS EXAMINATION ONLY,88300,HCPCS,310,RC,888300,CDM,,OUTPATIENT,,,81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL II - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88302,HCPCS,310,RC,888302,CDM,,OUTPATIENT,,,116.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL III - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMIN,88304,HCPCS,310,RC,888304,CDM,,OUTPATIENT,,,163,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL IV - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88305,HCPCS,310,RC,888305,CDM,,OUTPATIENT,,,163,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL V - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINAT,88307,HCPCS,310,RC,888307,CDM,,OUTPATIENT,,,954,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVEL VI - SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINA,88309,HCPCS,310,RC,888309,CDM,,OUTPATIENT,,,2147,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CO,88311,HCPCS,310,RC,888311,CDM,,OUTPATIENT,,,28.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP I F,88312,HCPCS,310,RC,888312,CDM,,OUTPATIENT,,,163,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT GROUP II,88313,HCPCS,310,RC,888313,CDM,,OUTPATIENT,,,111,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPA,88323,HCPCS,310,RC,888323,CDM,,OUTPATIENT,,,163,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88341,HCPCS,310,RC,888341,CDM,,OUTPATIENT,,,76.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN I,88342,HCPCS,310,RC,7010689,CDM,,OUTPATIENT,,,489,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY PER SPECIMEN E,88344,HCPCS,310,RC,888344,CDM,,OUTPATIENT,,,954,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY ST,88346,HCPCS,310,RC,888346,CDM,,OUTPATIENT,,,188.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNOFLUORESCENCE PER SPECIMEN EACH ADDITIONAL SINGLE ANT,88350,HCPCS,310,RC,888350,CDM,,OUTPATIENT,,,147.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY (EG HER-2,88360,HCPCS,310,RC,888360,CDM,,OUTPATIENT,,,489,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN EACH ADDITIO,88364,HCPCS,310,RC,888364,CDM,,OUTPATIENT,,,64.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IN SITU HYBRIDIZATION (EG FISH) PER SPECIMEN INITIAL SING,88365,HCPCS,310,RC,888365,CDM,,OUTPATIENT,,,489,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88368,HCPCS,310,RC,888368,CDM,,OUTPATIENT,,,954,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION (QUANTITATIVE O,88377,HCPCS,310,RC,888377,CDM,,OUTPATIENT,,,525.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MICRODISSECTION (IE SAMPLE PREPARATION OF MICROSCOPICALLY I,88381,HCPCS,310,RC,888381,CDM,,OUTPATIENT,,,90.64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010081,CDM,,OUTPATIENT,,,31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CELL COUNT MISCELLANEOUS BODY FLUIDS (EG CEREBROSPINAL FLU,89051,HCPCS,300,RC,7010057,CDM,,OUTPATIENT,,,31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEUKOCYTE ASSESSMENT FECAL QUALITATIVE OR SEMIQUANTITATIVE,89055,HCPCS,300,RC,7010087,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT P,89060,HCPCS,300,RC,7010080,CDM,,OUTPATIENT,,,28.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS VOLUME COUNT MOTILITY AND DIFFERENTIAL,89320,HCPCS,300,RC,7010164,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SEMEN ANALYSIS SPERM PRESENCE AND MOTILITY OF SPERM IF PER,89321,HCPCS,300,RC,7010163,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90460 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90460,HCPCS,983,RC,VFC90460,CDM,,OUTPATIENT,,,21.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90461: PEDIATRIC EACH ADDITIONAL,90461,HCPCS,510,RC,VAC90461,CDM,,OUTPATIENT,,,21.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90461 IMMUNIZATION COUNSELING AND ADMINISTRATION THROUG,90461,HCPCS,983,RC,VFC90461,CDM,,OUTPATIENT,,,21.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90471 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM 1 VACCINE,90471,HCPCS,983,RC,VFC90471,CDM,,OUTPATIENT,,,21.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,450,RC,6230211,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION 1 VACCINE,90471,HCPCS,983,RC,90471,CDM,,OUTPATIENT,,,45.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,VAC90471,CDM,,OUTPATIENT,,,71.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90471,HCPCS,771,RC,7200004,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,90471,HCPCS,771,RC,6230024,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADDITIONAL IMMUNIZATION ADMINISTRATION,90472,HCPCS,983,RC,90472,CDM,,OUTPATIENT,,,23.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90472: IM/SUBQ EACH ADDITIONAL,90472,HCPCS,636,RC,VAC90472,CDM,,OUTPATIENT,,,71.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,450,RC,6230025,CDM,,OUTPATIENT,,,73.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS INTRADER,90472,HCPCS,771,RC,7200005,CDM,,OUTPATIENT,,,73.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VFC 90472 IMMUNIZATION ADMIN PERC/ID/SUBQ/IM EACH ADDTL VAC,90472,HCPCS,983,RC,VFC90472,CDM,,OUTPATIENT,,,21.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90473: INTRANASAL/ORAL FIRST DOSE,90473,HCPCS,636,RC,VAC90473,CDM,,OUTPATIENT,,,32.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90474: INTRANASAL/ORAL EACH ADDITIONAL,90474,HCPCS,636,RC,VAC90474,CDM,,OUTPATIENT,,,24.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 18 YEARS,90480,HCPCS,771,RC,90480,CDM,,OUTPATIENT,,,80,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS A VACCINE (HEPA) ADULT DOSAGE FOR INTRAMUSCULAR,90632,HCPCS,983,RC,90632,CDM,,OUTPATIENT,,,132.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE,90633,HCPCS,983,RC,90633,CDM,,OUTPATIENT,,,67.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB) PRP-OMP CONJUGA,90647,HCPCS,983,RC,90647,CDM,,OUTPATIENT,,,71.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90658 INFLUENZA VIRUS VACCINE TRIVALENT SPLIT VIRUS 3 YRS,90658,HCPCS,983,RC,90658,CDM,,OUTPATIENT,,,16.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90662 OS INFLUENZA VIRUS VACCINE OVER 65,90662,HCPCS,983,RC,90662,CDM,,OUTPATIENT,,,193.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE HD 65+ YRS,90662,HCPCS,636,RC,589065,CDM,,OUTPATIENT,,,193.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT (PCV13) FOR INTRA,90670,HCPCS,983,RC,90670,CDM,,OUTPATIENT,,,214.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML PNEUMOCOCCAL 13-VALENT CONJUGATE,90670,HCPCS,636,RC,589089,CDM,,OUTPATIENT,,,474,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLUCELVAX PF QUAD SINGLE DOSE,90674,HCPCS,636,RC,589122,CDM,,OUTPATIENT,,,90,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90674 FLUCELVAX QUADRIVALENT (2022/2023) (PRESERVATIVE FREE),90674,HCPCS,983,RC,90674,CDM,,OUTPATIENT,,,79.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL 20-VALENT CONJUGATE,90677,HCPCS,636,RC,589092,CDM,,OUTPATIENT,,,470.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
90682 OS INFLUENZA VIRUS VACCINE OVER 50,90682,HCPCS,983,RC,90682,CDM,,OUTPATIENT,,,193.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FLU VACCINE 6+ MNTHS IM,90686,HCPCS,636,RC,589064,CDM,,OUTPATIENT,,,57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML MMR,90707,HCPCS,636,RC,589078,CDM,,OUTPATIENT,,,215,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SU,90707,HCPCS,983,RC,90707,CDM,,OUTPATIENT,,,82.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TD TOXOIDS,90714,HCPCS,636,RC,589097,CDM,,OUTPATIENT,,,84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,90714,HCPCS,983,RC,90714,CDM,,OUTPATIENT,,,32.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML TDAP,90715,HCPCS,636,RC,589047,CDM,,OUTPATIENT,,,131.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90715,HCPCS,983,RC,90715,CDM,,OUTPATIENT,,,63.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML VARICELLA,90716,HCPCS,636,RC,589104,CDM,,OUTPATIENT,,,264.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TDAP VACCINE 7 YRS/> IM,90716,HCPCS,983,RC,90716,CDM,,OUTPATIENT,,,264.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 23-VALENT (PPSV23) ADU,90732,HCPCS,983,RC,90732,CDM,,OUTPATIENT,,,127.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MENINGOCOCCAL CONJUGATE VACCINE SEROGROUPS A C W Y QUAD,90734,HCPCS,983,RC,90734,CDM,,OUTPATIENT,,,187.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,589061,CDM,,OUTPATIENT,,,198.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE F,90746,HCPCS,983,RC,90746,CDM,,OUTPATIENT,,,25.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5 ML ZOSTER,90750,HCPCS,636,RC,589106,CDM,,OUTPATIENT,,,385.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,983,RC,90791,CDM,,OUTPATIENT,,,376.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES,90792,HCPCS,983,RC,90792,CDM,,OUTPATIENT,,,315.18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT,90832,HCPCS,983,RC,90832,CDM,,OUTPATIENT,,,158.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 30 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90833,HCPCS,983,RC,90833,CDM,,OUTPATIENT,,,106.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT,90834,HCPCS,983,RC,90834,CDM,,OUTPATIENT,,,204.97,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 45 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90836,HCPCS,983,RC,90836,CDM,,OUTPATIENT,,,170.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT,90837,HCPCS,983,RC,90837,CDM,,OUTPATIENT,,,300.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSYCHOTHERAPY 60 MINUTES WITH PATIENT WHEN PERFORMED WITH A,90838,HCPCS,983,RC,90838,CDM,,OUTPATIENT,,,276.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 50 MINUT,90846,HCPCS,983,RC,90846,CDM,,OUTPATIENT,,,233.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT,90847,HCPCS,983,RC,90847,CDM,,OUTPATIENT,,,225.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP),90853,HCPCS,983,RC,90853,CDM,,OUTPATIENT,,,65.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYPNOTHERAPY,90880,HCPCS,360,RC,90880,CDM,,OUTPATIENT,,,229,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY STUDY W/INTERPRPT,91010,HCPCS,960,RC,91010,CDM,,OUTPATIENT,,,368,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/O,91013,HCPCS,960,RC,91013,CDM,,OUTPATIENT,,,13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT,91034,HCPCS,360,RC,91034,CDM,,OUTPATIENT,,,1496,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD,91035,HCPCS,750,RC,7210010,CDM,,OUTPATIENT,,,1599,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHAGUS GASTROESOPHAGEAL REFLUX TEST WITH MUCOSAL ATTACH,91035,HCPCS,750,RC,91035,CDM,,OUTPATIENT,,,1599,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD,91037,HCPCS,360,RC,91037,CDM,,OUTPATIENT,,,811,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG,91038,HCPCS,360,RC,91038,CDM,,OUTPATIENT,,,1496,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/IR,91110,HCPCS,360,RC,91110,CDM,,OUTPATIENT,,,2479,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91320 PFIZER (12Y+),91320,HCPCS,636,RC,589149,CDM,,OUTPATIENT,,,307.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
91322 MODERNA (12Y+),91322,HCPCS,636,RC,589154,CDM,,OUTPATIENT,,,311,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7081034,CDM,,OUTPATIENT,,,342.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AND/OR,92507,HCPCS,440,RC,7082018,CDM,,OUTPATIENT,,,342.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082002,CDM,,OUTPATIENT,,,342.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANG VOICE COMMJ AND/AUDITORY PROC IND,92507,HCPCS,440,RC,7082030,CDM,,OUTPATIENT,,,342.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV,92508,HCPCS,443,RC,7082005,CDM,,OUTPATIENT,,,226.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082013,CDM,,OUTPATIENT,,,77.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH FLUENCY (EG STUTTERING CLUTTERING),92521,HCPCS,444,RC,7082008,CDM,,OUTPATIENT,,,77.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPEECH SOUND PROD EVAL CHARGE MEDICAID,92522,HCPCS,449,RC,7082014,CDM,,OUTPATIENT,,,208.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE,92522,HCPCS,444,RC,7082007,CDM,,OUTPATIENT,,,208.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082000,CDM,,OUTPATIENT,,,422.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION,92523,HCPCS,444,RC,7082015,CDM,,OUTPATIENT,,,422.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082010,CDM,,OUTPATIENT,,,201.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE,92524,HCPCS,449,RC,7082001,CDM,,OUTPATIENT,,,201.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082009,CDM,,OUTPATIENT,,,256.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR,92526,HCPCS,440,RC,7082017,CDM,,OUTPATIENT,,,256.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,444,RC,7082006,CDM,,OUTPATIENT,,,148.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION,92610,HCPCS,449,RC,7082011,CDM,,OUTPATIENT,,,148.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082012,CDM,,OUTPATIENT,,,308,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082031,CDM,,OUTPATIENT,,,308,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CIN,92611,HCPCS,444,RC,7082004,CDM,,OUTPATIENT,,,308,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AUDITORY EVOKED POTENTIALS SCREENING OF AUDITORY POTENTIAL,92650,HCPCS,471,RC,6080003,CDM,,OUTPATIENT,,,294.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,92950,HCPCS,981,RC,6230096,CDM,,OUTPATIENT,,,435,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOPULMONARY RESUSCITATION (EG IN CARDIAC ARREST),92950,HCPCS,450,RC,929500,CDM,,OUTPATIENT,,,867,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY PACEMAKER,92953,HCPCS,450,RC,6230126,CDM,,OUTPATIENT,,,1025,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TEMPORARY TRANSCUTANEOUS PACING,92953,HCPCS,450,RC,6230204,CDM,,OUTPATIENT,,,1025,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,450,RC,929600,CDM,,OUTPATIENT,,,208.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVERSION ELECTIVE ELECTRICAL CONVERSION OF ARRHYTHMIA,92960,HCPCS,360,RC,92960,CDM,,OUTPATIENT,,,1841,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,360,RC,93005,CDM,,OUTPATIENT,,,182,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS TRACI,93005,HCPCS,730,RC,70300001,CDM,,OUTPATIENT,,,182,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,7046150,CDM,,OUTPATIENT,,,33.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 LEADS INTER,93010,HCPCS,983,RC,93010,CDM,,OUTPATIENT,,,33.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93016,HCPCS,960,RC,93016,CDM,,OUTPATIENT,,,111.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CV STRS TST XERS AND/OR RX CONT ECG TRCG ONLY,93017,HCPCS,482,RC,70300004,CDM,,OUTPATIENT,,,867,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93017,HCPCS,482,RC,7030021,CDM,,OUTPATIENT,,,599.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREAD,93018,HCPCS,960,RC,693018,CDM,,OUTPATIENT,,,61.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,70300003,CDM,,OUTPATIENT,,,231.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93225,HCPCS,731,RC,7030008,CDM,,OUTPATIENT,,,231.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ECG SCANNING ANALYSIS REPORT,93226,HCPCS,731,RC,70300002,CDM,,OUTPATIENT,,,550.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CO,93227,HCPCS,960,RC,93227,CDM,,OUTPATIENT,,,27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS,93270,HCPCS,731,RC,93270,CDM,,OUTPATIENT,,,192,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS,93271,HCPCS,731,RC,93271,CDM,,OUTPATIENT,,,589.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,93272,CDM,,OUTPATIENT,,,66.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EXTERNAL PATIENT AND WHEN PERFORMED AUTO ACTIVATED ELECTRO,93272,HCPCS,985,RC,7046164,CDM,,OUTPATIENT,,,69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93306,HCPCS,960,RC,7505170,CDM,,OUTPATIENT,,,125,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US ECHOCARDIOGRAM COMPLETE W/ COLOR,93306,HCPCS,483,RC,7043020,CDM,,OUTPATIENT,,,1583,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ECHOCARDIOGRAPHY TRANSTHORACIC REAL-TIME WITH IMAGE DOCUME,93307,HCPCS,483,RC,933070,CDM,,OUTPATIENT,,,1127.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY BLOOD PRESSURE MONITORING UTILIZING REPORT-GENER,93786,HCPCS,920,RC,70300007,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,960,RC,7505168,CDM,,OUTPATIENT,,,74.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES COMPLETE BILATERAL STU,93880,HCPCS,920,RC,7043018,CDM,,OUTPATIENT,,,1269.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,960,RC,7505169,CDM,,OUTPATIENT,,,47.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTRACRANIAL ARTERIES UNILATERAL OR LIMITED,93882,HCPCS,920,RC,7043019,CDM,,OUTPATIENT,,,414.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,960,RC,7505184,CDM,,OUTPATIENT,,,95.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93925,HCPCS,920,RC,7043032,CDM,,OUTPATIENT,,,754,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505185,CDM,,OUTPATIENT,,,59.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,93926,CDM,,OUTPATIENT,,,560,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,920,RC,7043033,CDM,,OUTPATIENT,,,560,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93926,HCPCS,960,RC,7505186,CDM,,OUTPATIENT,,,59.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,960,RC,7505205,CDM,,OUTPATIENT,,,53.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93930,HCPCS,920,RC,7043052,CDM,,OUTPATIENT,,,754,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505207,CDM,,OUTPATIENT,,,38.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,960,RC,7505206,CDM,,OUTPATIENT,,,38.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,939310,CDM,,OUTPATIENT,,,551.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS G,93931,HCPCS,920,RC,7043053,CDM,,OUTPATIENT,,,551,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,960,RC,7505187,CDM,,OUTPATIENT,,,84.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,920,RC,7043034,CDM,,OUTPATIENT,,,754,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93970,HCPCS,920,RC,7043067,CDM,,OUTPATIENT,,,754,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043069,CDM,,OUTPATIENT,,,567.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043068,CDM,,OUTPATIENT,,,567.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043036,CDM,,OUTPATIENT,,,567.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,920,RC,7043035,CDM,,OUTPATIENT,,,567.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505188,CDM,,OUTPATIENT,,,51.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRE,93971,HCPCS,960,RC,7505189,CDM,,OUTPATIENT,,,51.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505198,CDM,,OUTPATIENT,,,146.26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,960,RC,7505155,CDM,,OUTPATIENT,,,146.26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043056,CDM,,OUTPATIENT,,,633.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043045,CDM,,OUTPATIENT,,,633.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,920,RC,7043003,CDM,,OUTPATIENT,,,633.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMIN,93976,HCPCS,972,RC,7505342,CDM,,OUTPATIENT,,,633,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT 1ST DAY,94002,HCPCS,410,RC,70300021,CDM,,OUTPATIENT,,,1596,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VENTILATION ASSIST AND MGMT INPATIENT EA SBSQ DA,94003,HCPCS,410,RC,70300022,CDM,,OUTPATIENT,,,1596,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,7046162,CDM,,OUTPATIENT,,,457,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ,94010,HCPCS,460,RC,70300008,CDM,,OUTPATIENT,,,457,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,960,RC,7046160,CDM,,OUTPATIENT,,,457,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SPIROMETRY INCLUDING GRAPHIC RECORD TOTAL AND TIMED VITAL,94010,HCPCS,460,RC,94010,CDM,,OUTPATIENT,,,457,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,94060,CDM,,OUTPATIENT,,,980,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRONCHODILATION RESPONSIVENESS SPIROMETRY AS IN 94010 PRE-,94060,HCPCS,460,RC,70300009,CDM,,OUTPATIENT,,,867,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VITAL CAPACITY TOTAL (SEPARATE PROCEDURE),94150,HCPCS,460,RC,94150,CDM,,OUTPATIENT,,,428,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PULMONARY STRESS TESTING (EG 6-MINUTE WALK TEST) INCLUDING,94618,HCPCS,460,RC,946180,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,983,RC,94640,CDM,,OUTPATIENT,,,32.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE,94640,HCPCS,450,RC,6230129,CDM,,OUTPATIENT,,,616,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AEROSOL TREATMENT,94640,HCPCS,,,946400,CDM,,OUTPATIENT,,,375.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,94660,CDM,,OUTPATIENT,,,616,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300019,CDM,,OUTPATIENT,,,616,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) INIT,94660,HCPCS,410,RC,7030022,CDM,,OUTPATIENT,,,616,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CPAP VENTILATION CPAP INITIATION ANDMGMT,94660,HCPCS,410,RC,70300020,CDM,,OUTPATIENT,,,616,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,960,RC,94726,CDM,,OUTPATIENT,,,103,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG VOLUMES AND WHEN,94726,HCPCS,460,RC,942400,CDM,,OUTPATIENT,,,867,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GAS DILUTION OR WASHOUT FOR DETERMINATION OF LUNG VOLUMES AN,94727,HCPCS,460,RC,70300011,CDM,,OUTPATIENT,,,201.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,360,RC,94728,CDM,,OUTPATIENT,,,867,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AIRWAY RESISTANCE BY OSCILLOMETRY,94728,HCPCS,469,RC,70300012,CDM,,OUTPATIENT,,,867,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,94729,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DIFFUSING CAPACITY (EG CARBON MONOXIDE MEMBRANE) (LIST SEP,94729,HCPCS,460,RC,70300013,CDM,,OUTPATIENT,,,201.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION SIN,94760,HCPCS,960,RC,94760,CDM,,OUTPATIENT,,,4.12,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION MUL,94761,HCPCS,460,RC,70300014,CDM,,OUTPATIENT,,,63.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,70300015,CDM,,OUTPATIENT,,,457,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION BY,94762,HCPCS,460,RC,947620,CDM,,OUTPATIENT,,,457,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PULMONARY SERVICE OR PROCEDURE,94799,HCPCS,460,RC,70300018,CDM,,OUTPATIENT,,,294.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ALLERGY TESTING ANY COMBINATION OF PERCUTANEOUS (SCRATCH P,95018,HCPCS,510,RC,95018,CDM,,OUTPATIENT,,,63.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTI,95076,HCPCS,510,RC,95076,CDM,,OUTPATIENT,,,815.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDI,95117,HCPCS,,,95117,CDM,,OUTPATIENT,,,37.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,960,RC,95250,CDM,,OUTPATIENT,,,338.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TIS,95250,HCPCS,460,RC,7046147,CDM,,OUTPATIENT,,,364,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STUDY,95800,HCPCS,410,RC,7030009,CDM,,OUTPATIENT,,,460,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SLEEP STD AIRFLOW HRT RATE ANDO2 SAT EFFORT UNATT,95806,HCPCS,920,RC,70300023,CDM,,OUTPATIENT,,,460.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95810,HCPCS,920,RC,70300024,CDM,,OUTPATIENT,,,3014,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4,95811,HCPCS,920,RC,70300025,CDM,,OUTPATIENT,,,3014,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDDROWSY,95816,HCPCS,740,RC,70300016,CDM,,OUTPATIENT,,,867,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ELECTROENCEPHALOGRAM W/REC AWAKE ANDASLEEP,95819,HCPCS,740,RC,70300017,CDM,,OUTPATIENT,,,867,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 1-2 STUDIES,95907,HCPCS,922,RC,95907,CDM,,OUTPATIENT,,,96.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 3-4 STUDIES,95908,HCPCS,360,RC,95908,CDM,,OUTPATIENT,,,811,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 5-6 STUDIES,95909,HCPCS,360,RC,95909,CDM,,OUTPATIENT,,,811,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 7-8 STUDIES,95910,HCPCS,360,RC,95910,CDM,,OUTPATIENT,,,811,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 9-10 STUDIES,95911,HCPCS,360,RC,95911,CDM,,OUTPATIENT,,,1496,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 11-12 STUDIES,95912,HCPCS,360,RC,95912,CDM,,OUTPATIENT,,,1496,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NERVE CONDUCTION STUDIES 13 OR MORE STUDIES,95913,HCPCS,360,RC,95913,CDM,,OUTPATIENT,,,1496,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,940,RC,6230202,CDM,,OUTPATIENT,,,12.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CANALITH REPOSITIONING PROCEDURE(S) (EG EPLEY MANEUVER SEM,95992,HCPCS,981,RC,95992,CDM,,OUTPATIENT,,,77.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082003,CDM,,OUTPATIENT,,,228.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG ROSS INFORMA,96125,HCPCS,918,RC,7082016,CDM,,OUTPATIENT,,,228.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT I,96161,HCPCS,360,RC,96161,CDM,,OUTPATIENT,,,81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,7200018,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,6230010,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,450,RC,963600,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION INITIAL 31 MINUTES TO 1 HO,96360,HCPCS,260,RC,96360,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,96361,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,7200019,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION HYDRATION EACH ADDITIONAL HOUR (LIST,96361,HCPCS,260,RC,6230015,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96365,HCPCS,260,RC,9636559,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,7200023,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-59 INFUSION INITIAL ADDL SITE W/ MODIFICATION,96365,HCPCS,260,RC,963651,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,96365,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96365-INFUSION DRUG INITIAL UP TO 1 HR GREATER THAN 15 MINS,96365,HCPCS,260,RC,963650,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,96365,HCPCS,260,RC,6230008,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96366,HCPCS,260,RC,96366,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96366-INFUSE DRUG EACH ADDL HOUR GREATER THAN 30 MINS,96366,HCPCS,260,RC,963660,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,6230011,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THERAPY PROPHYLAXIS/DX EA ADDL HOUR,96366,HCPCS,260,RC,7200020,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,96367,CDM,,OUTPATIENT,,,267.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,6230012,CDM,,OUTPATIENT,,,267.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,96367,HCPCS,260,RC,7200022,CDM,,OUTPATIENT,,,267.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96367,HCPCS,260,RC,963670,CDM,,OUTPATIENT,,,268,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,96368,CDM,,OUTPATIENT,,,261.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INTRAVENOUS INFUSION FOR THERAPY PROPHYLAXIS OR DIAGNOSIS,96368,HCPCS,260,RC,7200010,CDM,,OUTPATIENT,,,261.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,963680,CDM,,OUTPATIENT,,,262,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,6230013,CDM,,OUTPATIENT,,,261.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,96368,HCPCS,260,RC,7200021,CDM,,OUTPATIENT,,,261.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,450,RC,6230084,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,7200026,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,96372,HCPCS,260,RC,6230016,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96372,HCPCS,960,RC,96372,CDM,,OUTPATIENT,,,45.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,963740,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,6230009,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,96374,HCPCS,260,RC,7200025,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96374,HCPCS,260,RC,96374,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,450,RC,963750,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96375 INF/NC IV PUSH EACH ADD'L SAME DRUG,96375,HCPCS,260,RC,7200024,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,96375,HCPCS,260,RC,6230014,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96375,HCPCS,260,RC,96375,CDM,,OUTPATIENT,,,131,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,963760,CDM,,OUTPATIENT,,,69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,260,RC,7200007,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY,96376,HCPCS,260,RC,96376,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,96376,HCPCS,450,RC,6230017,CDM,,OUTPATIENT,,,69.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF ON-BODY INJECTOR (INCLUDES CANNULA INSERTION),96377,HCPCS,230,RC,96377,CDM,,OUTPATIENT,,,148,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96380 ADMN RSV W/COUNSEL,96380,HCPCS,771,RC,96380,CDM,,OUTPATIENT,,,21.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 CHEMO BY SUB-Q IM NON HORMONAL CHARGE,96401,HCPCS,331,RC,96401,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96401 INF/C SUBCUT OR IM NON-HORMONAL,96401,HCPCS,331,RC,7200017,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 CHEMO ADM SQ/IM HORMONAL CHARGE,96402,HCPCS,331,RC,96402,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96402 INF/C SUBCUT OR IM HORMONAL,96402,HCPCS,331,RC,7200016,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 INF/C IV PUSH INITIAL/SINGLE DRUG,96409,HCPCS,331,RC,7200015,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96409 CHEMO IV PUSH SINGLE/INITIAL CHARGE,96409,HCPCS,331,RC,96409,CDM,,OUTPATIENT,,,670,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 INF/C IV PUSH EACH ADDT'L DRUG,96411,HCPCS,331,RC,7200014,CDM,,OUTPATIENT,,,203.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96411 CHEMO IV PUSH EA ADDL CHARGE,96411,HCPCS,331,RC,96411,CDM,,OUTPATIENT,,,203.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 CHEMO IV INFUSION 1ST HR CHARGE,96413,HCPCS,335,RC,96413,CDM,,OUTPATIENT,,,1045,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96413 INF/C IV INFUSION INITIAL/SINGLE,96413,HCPCS,335,RC,7200013,CDM,,OUTPATIENT,,,1045,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 INF/C INF EACH ADDITIONAL HOUR,96415,HCPCS,335,RC,7200012,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96415 CHEMO INFUS EA ADDL HR CHARGE,96415,HCPCS,335,RC,96415,CDM,,OUTPATIENT,,,203,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CHEMOTHERAPY ADMINISTRATION INTRAVENOUS INFUSION TECHNIQUE,96416,HCPCS,260,RC,7200009,CDM,,OUTPATIENT,,,1045,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 CHEMO IV INFUS EACH ADDL SEQ 1 HR CHARGE,96417,HCPCS,335,RC,96417,CDM,,OUTPATIENT,,,426.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96417 INF/C EACH SEQUENTIAL INFUSION,96417,HCPCS,335,RC,7200011,CDM,,OUTPATIENT,,,426.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
96521 SUBSEQUENT INFUSIONS,96521,HCPCS,260,RC,7200100,CDM,,OUTPATIENT,,,336,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVE,96523,HCPCS,761,RC,96523,CDM,,OUTPATIENT,,,182,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST,96523,HCPCS,761,RC,7200006,CDM,,OUTPATIENT,,,182,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PT UNATTENDED E-STIM UNITS,97014,HCPCS,420,RC,7080033,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081027,CDM,,OUTPATIENT,,,63.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081016,CDM,,OUTPATIENT,,,63.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
APPLICATION OF A MODALITY TO 1 OR MORE AREAS ULTRASOUND EA,97035,HCPCS,430,RC,7081017,CDM,,OUTPATIENT,,,63.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080032,CDM,,OUTPATIENT,,,74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080018,CDM,,OUTPATIENT,,,74.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,420,RC,7080029,CDM,,OUTPATIENT,,,74.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES THE,97110,HCPCS,420,RC,7080020,CDM,,OUTPATIENT,,,74.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081014,CDM,,OUTPATIENT,,,74.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081015,CDM,,OUTPATIENT,,,74.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES,97110,HCPCS,430,RC,7081026,CDM,,OUTPATIENT,,,74.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080013,CDM,,OUTPATIENT,,,98.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,420,RC,7080002,CDM,,OUTPATIENT,,,98.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES NEU,97112,HCPCS,430,RC,971120,CDM,,OUTPATIENT,,,99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080023,CDM,,OUTPATIENT,,,98.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA,97112,HCPCS,420,RC,7080014,CDM,,OUTPATIENT,,,98.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES GAI,97116,HCPCS,420,RC,7080000,CDM,,OUTPATIENT,,,98.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080008,CDM,,OUTPATIENT,,,98.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR,97116,HCPCS,420,RC,7080007,CDM,,OUTPATIENT,,,98.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080012,CDM,,OUTPATIENT,,,86.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080011,CDM,,OUTPATIENT,,,86.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURE 1 OR MORE AREAS EACH 15 MINUTES MAS,97124,HCPCS,420,RC,7080022,CDM,,OUTPATIENT,,,86.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,430,RC,7081000,CDM,,OUTPATIENT,,,86.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,97129,HCPCS,430,RC,7081001,CDM,,OUTPATIENT,,,86.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97129,HCPCS,440,RC,7081035,CDM,,OUTPATIENT,,,86.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (,97130,HCPCS,434,RC,7081006,CDM,,OUTPATIENT,,,46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080001,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TECHNIQUES (EG MOBILIZATION/ MANIPULATION M,97140,HCPCS,420,RC,7080003,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080009,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080010,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES,97140,HCPCS,420,RC,7080021,CDM,,OUTPATIENT,,,141.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS,97150,HCPCS,420,RC,97150,CDM,,OUTPATIENT,,,121,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080025,CDM,,OUTPATIENT,,,181.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY REQUIRING THESE,97161,HCPCS,424,RC,7080005,CDM,,OUTPATIENT,,,181.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080026,CDM,,OUTPATIENT,,,202.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY REQUIRING,97162,HCPCS,424,RC,7080006,CDM,,OUTPATIENT,,,202.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080004,CDM,,OUTPATIENT,,,224.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY REQUIRING THES,97163,HCPCS,424,RC,7080024,CDM,,OUTPATIENT,,,224.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080027,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE,97164,HCPCS,424,RC,7080015,CDM,,OUTPATIENT,,,120.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081005,CDM,,OUTPATIENT,,,182.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION LOW COMPLEXITY REQUIRING T,97165,HCPCS,434,RC,7081021,CDM,,OUTPATIENT,,,182.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION MODERATE COMPLEXITY REQUIR,97166,HCPCS,434,RC,7081022,CDM,,OUTPATIENT,,,196.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081004,CDM,,OUTPATIENT,,,219.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OCCUPATIONAL THERAPY EVALUATION HIGH COMPLEXITY REQUIRING,97167,HCPCS,434,RC,7081020,CDM,,OUTPATIENT,,,219.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081023,CDM,,OUTPATIENT,,,103,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CA,97168,HCPCS,434,RC,7081007,CDM,,OUTPATIENT,,,103,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081025,CDM,,OUTPATIENT,,,79.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUTIC ACTIVITIES DIRECT (ONE-ON-ONE) PATIENT CONTACT,97530,HCPCS,420,RC,7080019,CDM,,OUTPATIENT,,,79.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080017,CDM,,OUTPATIENT,,,79.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080016,CDM,,OUTPATIENT,,,79.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,420,RC,7080028,CDM,,OUTPATIENT,,,79.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081012,CDM,,OUTPATIENT,,,79.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,97530,HCPCS,430,RC,7081013,CDM,,OUTPATIENT,,,79.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081010,CDM,,OUTPATIENT,,,86.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081011,CDM,,OUTPATIENT,,,86.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING,97533,HCPCS,430,RC,7081024,CDM,,OUTPATIENT,,,86.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081018,CDM,,OUTPATIENT,,,113.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MANAGEMENT TRAINING (EG ACTIVITIES OF DAILY,97535,HCPCS,430,RC,7081008,CDM,,OUTPATIENT,,,113.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES,97535,HCPCS,430,RC,7081009,CDM,,OUTPATIENT,,,113.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081003,CDM,,OUTPATIENT,,,113.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN,97537,HCPCS,430,RC,7081019,CDM,,OUTPATIENT,,,113.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COMMUNITY/WORK REINTEGRATION TRAINING (EG SHOPPING TRANSPO,97537,HCPCS,430,RC,7081002,CDM,,OUTPATIENT,,,113.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WHEELCHAIR MANAGEMENT (EG ASSESSMENT FITTING TRAINING) E,97542,HCPCS,420,RC,7080031,CDM,,OUTPATIENT,,,62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,97597,HCPCS,450,RC,6230085,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
97597 DEBRIDE OPEN WOUND 1ST 20 SQ CM,97597,HCPCS,360,RC,97597,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM,97605,HCPCS,761,RC,97605,CDM,,OUTPATIENT,,,588,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WOUND VAC GREATER THAN 50 SQUARE CM,97606,HCPCS,761,RC,97606,CDM,,OUTPATIENT,,,700.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NEGATIVE PRESSURE WOUND THERAPY (EG VACUUM ASSISTED DRAINA,97607,HCPCS,230,RC,7047029,CDM,,OUTPATIENT,,,373,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY INITIAL ASSESSMENT AND INTERVENTI,97802,HCPCS,942,RC,97802,CDM,,OUTPATIENT,,,41.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERVENTION I,97803,HCPCS,942,RC,97803,CDM,,OUTPATIENT,,,42.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICAL NUTRITION THERAPY GROUP (2 OR MORE INDIVIDUAL(S)),97804,HCPCS,942,RC,97804,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS I,98925,HCPCS,530,RC,98925,CDM,,OUTPATIENT,,,87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 3-4 BODY REGIONS I,98926,HCPCS,530,RC,98926,CDM,,OUTPATIENT,,,87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,530,RC,98927,CDM,,OUTPATIENT,,,87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 5-6 BODY REGIONS I,98927,HCPCS,450,RC,6230206,CDM,,OUTPATIENT,,,87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 7-8 BODY REGIONS I,98928,HCPCS,530,RC,98928,CDM,,OUTPATIENT,,,87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,300,RC,7010070,CDM,,OUTPATIENT,,,48.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE,99000,HCPCS,960,RC,G2023,CDM,,OUTPATIENT,,,47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99024 POSTOPERATIVE FOLLOW UP VISIT,99024,HCPCS,960,RC,99024,CDM,,OUTPATIENT,,,14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FORM FILLING,99080,HCPCS,960,RC,FORM,CDM,,OUTPATIENT,,,15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/<,99100,HCPCS,964,RC,99100,CDM,,OUTPATIENT,,,111,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY,99140,HCPCS,964,RC,99140,CDM,,OUTPATIENT,,,111,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,HCPCS,450,RC,6230212,CDM,,OUTPATIENT,,,76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,HCPCS,450,RC,99152,CDM,,OUTPATIENT,,,70,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,HCPCS,450,RC,99153,CDM,,OUTPATIENT,,,70,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,7200008,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHLEBOTOMY THERAPEUTIC (SEPARATE PROCEDURE),99195,HCPCS,940,RC,99195,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99202 OFFICE VISIT LEVEL 2 NEW,99202,HCPCS,960,RC,99202,CDM,,OUTPATIENT,,,197.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99203 OFFICE VISIT LEVEL 3 NEW,99203,HCPCS,960,RC,99203,CDM,,OUTPATIENT,,,263.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99204 OFFICE VISIT LEVEL 4 NEW,99204,HCPCS,960,RC,99204,CDM,,OUTPATIENT,,,397.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99205 OFFICE VISIT LEVEL 5 NEW,99205,HCPCS,510,RC,99205,CDM,,OUTPATIENT,,,71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99211,HCPCS,960,RC,99211,CDM,,OUTPATIENT,,,32.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANA,99212,HCPCS,519,RC,992010,CDM,,OUTPATIENT,,,143.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99212 OFFICE VISIT LEVEL 2 EST,99212,HCPCS,960,RC,99212,CDM,,OUTPATIENT,,,134.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99213 OFFICE VISIT LEVEL 3 EST,99213,HCPCS,960,RC,99213,CDM,,OUTPATIENT,,,126.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99214 OFFICE VISIT LEVEL 4 EST,99214,HCPCS,960,RC,99214,CDM,,OUTPATIENT,,,183.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99215 OFFICE VISIT LEVEL 5 EST,99215,HCPCS,960,RC,99215,CDM,,OUTPATIENT,,,258.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO B,99217,HCPCS,960,RC,99217,CDM,,OUTPATIENT,,,176.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99218,HCPCS,960,RC,99218,CDM,,OUTPATIENT,,,242.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99219 INITIAL OBSERVATION VISIT MODERATE,99219,HCPCS,960,RC,99219,CDM,,OUTPATIENT,,,329.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99221 INITIAL HOSPITAL CARE PER DAY LOW SEVERITY,99221,HCPCS,960,RC,99221,CDM,,OUTPATIENT,,,248.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL OBSERVATION CARE PER DAY FOR THE EVALUATION AND MA,99222,HCPCS,960,RC,99220,CDM,,OUTPATIENT,,,450.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99222 INITIAL HOSPITAL CARE PER DAY MODERATE SEVERITY,99222,HCPCS,960,RC,99222,CDM,,OUTPATIENT,,,334.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99223 INITIAL HOSPITAL CARE PER DAY HIGH SEVERITY,99223,HCPCS,960,RC,99223,CDM,,OUTPATIENT,,,353.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99224,HCPCS,960,RC,99224,CDM,,OUTPATIENT,,,95.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99225,HCPCS,960,RC,99225,CDM,,OUTPATIENT,,,176.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT OBSERVATION CARE PER DAY FOR THE EVALUATION AND,99226,HCPCS,960,RC,99226,CDM,,OUTPATIENT,,,254.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99231 SUBSEQUENT HOSPITAL CARE LEVEL 1,99231,HCPCS,960,RC,99231,CDM,,OUTPATIENT,,,76.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99232 SUBSEQUENT HOSPITAL CARE LEVEL 2,99232,HCPCS,960,RC,99232,CDM,,OUTPATIENT,,,157.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99233 SUBSEQUENT HOSPITAL CARE LEVEL 3,99233,HCPCS,960,RC,99233,CDM,,OUTPATIENT,,,185.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99234 SAME DAY ADMIT/DISCHARGE LOW,99234,HCPCS,960,RC,99234,CDM,,OUTPATIENT,,,233.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99235 SAME DAY ADMIT/DISCHARGE MODERATE,99235,HCPCS,960,RC,99235,CDM,,OUTPATIENT,,,294.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99236 SAME DAY ADMIT/DISCHARGE HIGH,99236,HCPCS,960,RC,99236,CDM,,OUTPATIENT,,,380.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MINUTES OR LESS,99238,HCPCS,960,RC,99238,CDM,,OUTPATIENT,,,130.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL DISCHARGE DAY MANAGEMENT MORE THAN 30 MINUTES,99239,HCPCS,960,RC,99239,CDM,,OUTPATIENT,,,191.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99241,HCPCS,,,99241,CDM,,OUTPATIENT,,,36.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHICH,99242,HCPCS,960,RC,99242,CDM,,OUTPATIENT,,,138.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99243 OFFICE CONSULTATION LEVEL 3,99243,HCPCS,960,RC,99243,CDM,,OUTPATIENT,,,190.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99244 OFFICE CONSULTATION LEVEL 4,99244,HCPCS,510,RC,99244,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99245 OFFICE CONSULTATION LEVEL 5,99245,HCPCS,510,RC,99245,CDM,,OUTPATIENT,,,100,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT WHI,99251,HCPCS,960,RC,99251,CDM,,OUTPATIENT,,,96.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99252 INPATIENT CONSULTATION LEVEL 2,99252,HCPCS,960,RC,99252,CDM,,OUTPATIENT,,,150.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99253 INPATIENT CONSULTATION LEVEL 3,99253,HCPCS,960,RC,99253,CDM,,OUTPATIENT,,,228.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99254 INPATIENT CONSULTATION LEVEL 4,99254,HCPCS,960,RC,99254,CDM,,OUTPATIENT,,,332.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99255 INPATIENT CONSULTATION LEVEL 5,99255,HCPCS,960,RC,99255,CDM,,OUTPATIENT,,,403.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99281,HCPCS,981,RC,99281,CDM,,OUTPATIENT,,,136.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 1,99281,HCPCS,450,RC,6230001,CDM,,OUTPATIENT,,,238,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99282 ER LOW PRO FEE,99282,HCPCS,981,RC,99282,CDM,,OUTPATIENT,,,227.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 2,99282,HCPCS,450,RC,6230002,CDM,,OUTPATIENT,,,430,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 3,99283,HCPCS,450,RC,6230003,CDM,,OUTPATIENT,,,758,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99283 ER MOD PRO FEE,99283,HCPCS,981,RC,99283,CDM,,OUTPATIENT,,,364.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT,99284,HCPCS,981,RC,99284,CDM,,OUTPATIENT,,,585.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 4,99284,HCPCS,450,RC,6230004,CDM,,OUTPATIENT,,,1192,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99285 ER HIGH PRO FEE,99285,HCPCS,981,RC,99285,CDM,,OUTPATIENT,,,862.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HOSPITAL ED E ANDM LEVEL 5,99285,HCPCS,450,RC,6230005,CDM,,OUTPATIENT,,,1711,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE EVALUATION AND MANAGEMENT OF THE CRITICALLY I,99291,HCPCS,450,RC,6230246,CDM,,OUTPATIENT,,,1592.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,99291,HCPCS,450,RC,6230006,CDM,,OUTPATIENT,,,2441,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99291 CRITICAL CARE FIRST 30-74 MIN,99291,HCPCS,960,RC,99291,CDM,,OUTPATIENT,,,488.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99292 CRITICAL CARE EACH ADDITIONAL 30 MIN,99292,HCPCS,960,RC,99292,CDM,,OUTPATIENT,,,216.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,99292,HCPCS,450,RC,6230007,CDM,,OUTPATIENT,,,448.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99304 INITIAL NURSING FACILITY CARE LOW,99304,HCPCS,960,RC,99304,CDM,,OUTPATIENT,,,162.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99305 INITIAL NURSING FACILITY CARE MODERATE,99305,HCPCS,960,RC,99305,CDM,,OUTPATIENT,,,230.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99306 INITIAL NURSING FACILITY CARE HIGH,99306,HCPCS,960,RC,99306,CDM,,OUTPATIENT,,,292.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99307 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 1,99307,HCPCS,960,RC,99307,CDM,,OUTPATIENT,,,80.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99308 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 2,99308,HCPCS,960,RC,99308,CDM,,OUTPATIENT,,,121.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99309 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 3,99309,HCPCS,960,RC,99309,CDM,,OUTPATIENT,,,160.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99310 NURSING HOME PHYSICAL SUBSEQUENT LEVEL 4,99310,HCPCS,960,RC,99310,CDM,,OUTPATIENT,,,234.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT 30 MINUTES OR LES,99315,HCPCS,960,RC,99315,CDM,,OUTPATIENT,,,126.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NURSING FACILITY DISCHARGE DAY MANAGEMENT MORE THAN 30 MINU,99316,HCPCS,960,RC,99316,CDM,,OUTPATIENT,,,251.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN,99318,HCPCS,960,RC,99318,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGE,99324,HCPCS,960,RC,99324,CDM,,OUTPATIENT,,,96.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN,99325,HCPCS,960,RC,99325,CDM,,OUTPATIENT,,,139.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN,99327,HCPCS,960,RC,99327,CDM,,OUTPATIENT,,,326.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES,99328,HCPCS,960,RC,99328,CDM,,OUTPATIENT,,,376.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES,99334,HCPCS,,,99334,CDM,,OUTPATIENT,,,132.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES,99335,HCPCS,522,RC,99335,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES,99336,HCPCS,522,RC,99336,CDM,,OUTPATIENT,,,235.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES,99337,HCPCS,522,RC,99337,CDM,,OUTPATIENT,,,326.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99356,HCPCS,960,RC,99356,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED SERVICE IN THE INPATIENT OR OBSERVATION SETTING R,99357,HCPCS,960,RC,99357,CDM,,OUTPATIENT,,,167.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99381 PREVENTIVE EVAL INITIAL NEW PT. < 1 YEAR AGE,99381,HCPCS,960,RC,99381,CDM,,OUTPATIENT,,,183.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99382 PREVENTIVE EVAL INITIAL NEW PT. 1-4 YEAR AGE,99382,HCPCS,960,RC,99382,CDM,,OUTPATIENT,,,197.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,99383,HCPCS,960,RC,99383,CDM,,OUTPATIENT,,,191.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99384 PREVENTIVE EVAL INITIAL NEW PT. 12-17 YEAR AGE,99384,HCPCS,960,RC,99384,CDM,,OUTPATIENT,,,210.12,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PREVENTIVE EVAL INITIAL NEW PT. 18-39 YEAR AGE,99385,HCPCS,960,RC,99385,CDM,,OUTPATIENT,,,210.12,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,99386,HCPCS,960,RC,99386,CDM,,OUTPATIENT,,,21.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS AND>,99387,HCPCS,960,RC,99387,CDM,,OUTPATIENT,,,21.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99391 PREVENTIVE EVAL EST PT. < 1 YEAR AGE,99391,HCPCS,960,RC,99391,CDM,,OUTPATIENT,,,148.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99392 PREVENTIVE EVAL EST PT. 1-4 YEAR AGE,99392,HCPCS,960,RC,99392,CDM,,OUTPATIENT,,,161.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99393 PREVENTIVE EVAL EST PT. 5-11 YEAR AGE,99393,HCPCS,960,RC,99393,CDM,,OUTPATIENT,,,161.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,960,RC,99394,CDM,,OUTPATIENT,,,176.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99395 PREVENTIVE EVAL EST PT. 18-39 YEAR AGE,99395,HCPCS,960,RC,99395,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,99396,HCPCS,510,RC,99396,CDM,,OUTPATIENT,,,72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,99406,HCPCS,942,RC,6230087,CDM,,OUTPATIENT,,,86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
99406 SMOKING/TOBACCO CESSATION COUNSELING 3-10 MIN,99406,HCPCS,960,RC,99406,CDM,,OUTPATIENT,,,32.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTERMED,99406,HCPCS,942,RC,994061,CDM,,OUTPATIENT,,,86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,6230148,CDM,,OUTPATIENT,,,67,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,981,RC,6235021,CDM,,OUTPATIENT,,,62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT INTENSIV,99407,HCPCS,450,RC,994070,CDM,,OUTPATIENT,,,67,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,99417,HCPCS,960,RC,99417,CDM,,OUTPATIENT,,,175,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT,99418,HCPCS,960,RC,99418,CDM,,OUTPATIENT,,,166.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UNLISTED PREVENTIVE MEDICINE SERVICE,99429,HCPCS,983,RC,99429,CDM,,OUTPATIENT,,,126.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DOT PHYSICAL,99455,HCPCS,521,RC,5006,CDM,,OUTPATIENT,,,180.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WORK RELATED/MED DBLT XM TREATING PHYS,99455,HCPCS,960,RC,99455,CDM,,OUTPATIENT,,,175.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PRE EMPLOYMENT PHYSICAL,99455,HCPCS,521,RC,5005,CDM,,OUTPATIENT,,,180.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99460,HCPCS,960,RC,99460,CDM,,OUTPATIENT,,,154.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT HOSPITAL CARE PER DAY FOR EVALUATION AND MANAGE,99462,HCPCS,960,RC,99462,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL OR BIRTHING CENTER CARE PER DAY FOR EVALU,99463,HCPCS,960,RC,99463,CDM,,OUTPATIENT,,,196.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ATTENDANCE AT DELIVERY AND INITIAL STABILIZATION OF NEWB,99464,HCPCS,960,RC,99464,CDM,,OUTPATIENT,,,139.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DELIVERY/BIRTHING ROOM RESUSCITATION PROVISION OF POSITIVE,99465,HCPCS,960,RC,99465,CDM,,OUTPATIENT,,,249.26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CRITICAL CARE FACE-TO-FACE SERVICES DURING AN INTERFACILITY,99466,HCPCS,960,RC,99466,CDM,,OUTPATIENT,,,448.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT NEONATAL CRITICAL CARE PER DAY FOR THE E,99468,HCPCS,960,RC,99468,CDM,,OUTPATIENT,,,1617.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE PER DAY FOR TH,99469,HCPCS,960,RC,99469,CDM,,OUTPATIENT,,,670.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL INPATIENT PEDIATRIC CRITICAL CARE PER DAY FOR THE,99471,HCPCS,960,RC,99471,CDM,,OUTPATIENT,,,1450.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INITIAL HOSPITAL CARE PER DAY FOR THE EVALUATION AND MANAG,99477,HCPCS,960,RC,99477,CDM,,OUTPATIENT,,,807.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SUBSEQUENT INTENSIVE CARE PER DAY FOR THE EVALUATION AND M,99479,HCPCS,960,RC,99479,CDM,,OUTPATIENT,,,273.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99495,HCPCS,960,RC,99495,CDM,,OUTPATIENT,,,290,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TRANSITIONAL CARE MANAGEMENT SERVICES WITH THE FOLLOWING REQ,99496,HCPCS,960,RC,99496,CDM,,OUTPATIENT,,,393,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING FIRST 30 MINS,99497,HCPCS,960,RC,99497,CDM,,OUTPATIENT,,,190.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ADVANCE CARE PLANNING EA ADDL 30 MINS,99498,HCPCS,960,RC,99498,CDM,,OUTPATIENT,,,172.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINI,G0101,HCPCS,300,RC,G0101,CDM,,OUTPATIENT,,,67,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,300,RC,G0102,CDM,,OUTPATIENT,,,35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROLONG INPT EVAL ADD15 M,G0316,HCPCS,960,RC,G0316,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OPIOIDS AND OPIATE ANALOGS 1 OR 2,G0480,HCPCS,300,RC,7010484,CDM,,OUTPATIENT,,,75.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
REMOT IMAGE SUBMIT BY PT,G2010,HCPCS,,,G2010,CDM,,OUTPATIENT,,,18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BRIEF CHECK IN BY MD/QHP,G2012,HCPCS,,,G2012,CDM,,OUTPATIENT,,,21,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2061,HCPCS,,,G2061,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2062,HCPCS,,,G2062,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MEDICARE TELEHEALTH VISIT,G2063,HCPCS,,,G2063,CDM,,OUTPATIENT,,,69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1010 INJECTION METHYLPREDNISOLONE ACETATE 1 MG,J1010,HCPCS,636,RC,J1010,CDM,,OUTPATIENT,,,1.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,J1050,CDM,,OUTPATIENT,,,1.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,J1100,HCPCS,983,RC,J1100,CDM,,OUTPATIENT,,,2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,J1885,CDM,,OUTPATIENT,,,7.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3301 INJECTION TRIAMCINOLONE ACETONIDE 10 MG,J3301,HCPCS,983,RC,J3301,CDM,,OUTPATIENT,,,2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SY,J7301,HCPCS,278,RC,J7301,CDM,,OUTPATIENT,,,600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE EUFLEXXA FOR INTRA-ARTICULA,J7323,HCPCS,636,RC,J7323,CDM,,OUTPATIENT,,,612,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HYALURONAN OR DERIVATIVE MONOVISC FOR INTRA-ARTICULAR INJECTION PER DOSE,J7327,HCPCS,636,RC,J7327,CDM,,OUTPATIENT,,,2075,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010020,CDM,,OUTPATIENT,,,617,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010016,CDM,,OUTPATIENT,,,617,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010019,CDM,,OUTPATIENT,,,617,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9016,HCPCS,390,RC,7010018,CDM,,OUTPATIENT,,,617,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010247,CDM,,OUTPATIENT,,,336.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010249,CDM,,OUTPATIENT,,,336.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010248,CDM,,OUTPATIENT,,,336.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010246,CDM,,OUTPATIENT,,,336.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FRESH FROZEN PLASMA (SINGLE DONOR) FROZEN WITHIN 8 HOURS OF,P9017,HCPCS,390,RC,7010244,CDM,,OUTPATIENT,,,336.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLASMA CRYOPRECIPITATE REDUCED PATHOGEN REDUCED EACH UNIT,P9025,HCPCS,390,RC,7010243,CDM,,OUTPATIENT,,,336.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3087 APH PLT ACDA LR 1,P9034,HCPCS,390,RC,7010025,CDM,,OUTPATIENT,,,1602.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3077 APH PLT ACDA LR,P9034,HCPCS,390,RC,7010024,CDM,,OUTPATIENT,,,1602.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3089 APH PLT ACDA LR 3,P9034,HCPCS,390,RC,7010027,CDM,,OUTPATIENT,,,1602.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3088 APH PLT ACDA LR 2,P9034,HCPCS,390,RC,7010026,CDM,,OUTPATIENT,,,1602.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3057 APH PLT ACDA LR IRR 2,P9037,HCPCS,390,RC,7010022,CDM,,OUTPATIENT,,,1896.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3056 APH PLT ACDA LR IRR 1,P9037,HCPCS,390,RC,7010021,CDM,,OUTPATIENT,,,1896.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
E3058 APH PLT ACDA LR IRR 3,P9037,HCPCS,390,RC,7010023,CDM,,OUTPATIENT,,,1896.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010015,CDM,,OUTPATIENT,,,617,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
RED BLOOD CELLS LEUKOCYTES REDUCED EACH UNIT,P9040,HCPCS,390,RC,7010017,CDM,,OUTPATIENT,,,617,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT,P9073,HCPCS,300,RC,P9073,CDM,,OUTPATIENT,,,804,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
SCREENING PAPANICOLAOU SMEAR,Q0091,HCPCS,521,RC,Q0091,CDM,,OUTPATIENT,,,26.37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
UPPER EXT FX ORTHOSIS WRIST,,,270,RC,75041176,CDM,,OUTPATIENT,,,185.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VACCINE ADMINISTRATION,,,771,RC,M0247,CDM,,OUTPATIENT,,,901,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IPRATROPIUM-ALBUTEROL,,,636,RC,589066,CDM,,OUTPATIENT,,,0.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,,,983,RC,J0696,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1335 INJECTION ERTAPENEM SODIUM PER 500MG,,,983,RC,J1335,CDM,,OUTPATIENT,,,140.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046137,CDM,,OUTPATIENT,,,9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J2791 INJECTION RHO(D) IMMUNE GLOBULIN IM OR IV 100 IU,,,983,RC,J2791,CDM,,OUTPATIENT,,,23.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J3420 INJECTION VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG,,,983,RC,J3420,CDM,,OUTPATIENT,,,39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7321 HYALURONAN OR DERIVATIVE HYALGAN SUPARTZ OR VISCO-3,,,983,RC,J7321,CDM,,OUTPATIENT,,,498.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7324 INJECTION HYALURONAN OR DERIVATIVE ORTHOVISC FOR IN,,,983,RC,588810,CDM,,OUTPATIENT,,,502,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
J7326 HYALURONAN OR DERIVATIVE GEL-ONE FOR INTRA-ARTICULAR,,,983,RC,J7326,CDM,,OUTPATIENT,,,1380,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
KO ELASTIC W/JOINTS PRE OTS,,,274,RC,75041105,CDM,,OUTPATIENT,,,212.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY HIGH RISK,,,720,RC,60920001,CDM,,OUTPATIENT,,,2725,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LABOR DELIVERY NORMAL,,,720,RC,60920000,CDM,,OUTPATIENT,,,2181,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE TOPICAL,,,250,RC,589075,CDM,,OUTPATIENT,,,7.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LIDOCAINE-EPINEPHRINE,,,250,RC,589076,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L OT,,,480,RC,7081032,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH ADD'L ST,,,444,RC,7082026,CDM,,OUTPATIENT,,,103,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL OT,,,480,RC,7081031,CDM,,OUTPATIENT,,,77.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH INITIAL ST,,,444,RC,7082025,CDM,,OUTPATIENT,,,77.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH FOLLOW-UP VISIT,,,990,RC,7082022,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH MILEAGE,,,990,RC,7082027,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH REASSESS,,,990,RC,7082023,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
VHH SPEECH SUPERVISION,,,990,RC,7082024,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
WELCOME TO MEDICARE 12 LEAD,,,730,RC,G0404,CDM,,OUTPATIENT,,,130.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
TREATMENT ROOM,,,761,RC,7420003,CDM,,OUTPATIENT,,,229,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ULTRASLING IV DONJOY MEDIUM,,,274,RC,62102591,CDM,,OUTPATIENT,,,124.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040138,CDM,,OUTPATIENT,,,217,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,7040144,CDM,,OUTPATIENT,,,206,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101000,CDM,,OUTPATIENT,,,115.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101018,CDM,,OUTPATIENT,,,44.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101019,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101028,CDM,,OUTPATIENT,,,40.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101030,CDM,,OUTPATIENT,,,301.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101039,CDM,,OUTPATIENT,,,41.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101040,CDM,,OUTPATIENT,,,3.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101041,CDM,,OUTPATIENT,,,56.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101049,CDM,,OUTPATIENT,,,40.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101121,CDM,,OUTPATIENT,,,98.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101122,CDM,,OUTPATIENT,,,107.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101180,CDM,,OUTPATIENT,,,159,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101181,CDM,,OUTPATIENT,,,148.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101182,CDM,,OUTPATIENT,,,157.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101183,CDM,,OUTPATIENT,,,360,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101184,CDM,,OUTPATIENT,,,148.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101187,CDM,,OUTPATIENT,,,285,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101188,CDM,,OUTPATIENT,,,315,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101189,CDM,,OUTPATIENT,,,270,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101190,CDM,,OUTPATIENT,,,4125.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101191,CDM,,OUTPATIENT,,,1650,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101192,CDM,,OUTPATIENT,,,7020.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101193,CDM,,OUTPATIENT,,,987,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101194,CDM,,OUTPATIENT,,,1017,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101195,CDM,,OUTPATIENT,,,960,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101201,CDM,,OUTPATIENT,,,792,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101207,CDM,,OUTPATIENT,,,107.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101208,CDM,,OUTPATIENT,,,107.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101209,CDM,,OUTPATIENT,,,107.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101210,CDM,,OUTPATIENT,,,107.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101213,CDM,,OUTPATIENT,,,107.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101215,CDM,,OUTPATIENT,,,96.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101216,CDM,,OUTPATIENT,,,283.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101217,CDM,,OUTPATIENT,,,107.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101218,CDM,,OUTPATIENT,,,297.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101219,CDM,,OUTPATIENT,,,384.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101220,CDM,,OUTPATIENT,,,384.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101221,CDM,,OUTPATIENT,,,324,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101222,CDM,,OUTPATIENT,,,338.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101223,CDM,,OUTPATIENT,,,107.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101224,CDM,,OUTPATIENT,,,244.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101225,CDM,,OUTPATIENT,,,244.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101239,CDM,,OUTPATIENT,,,621.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101297,CDM,,OUTPATIENT,,,349.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101299,CDM,,OUTPATIENT,,,72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101301,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101304,CDM,,OUTPATIENT,,,684,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101305,CDM,,OUTPATIENT,,,693,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101313,CDM,,OUTPATIENT,,,115.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101322,CDM,,OUTPATIENT,,,1890,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101328,CDM,,OUTPATIENT,,,4578,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101330,CDM,,OUTPATIENT,,,90,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101332,CDM,,OUTPATIENT,,,79.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101334,CDM,,OUTPATIENT,,,90,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101336,CDM,,OUTPATIENT,,,90,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101337,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101338,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101339,CDM,,OUTPATIENT,,,561,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101341,CDM,,OUTPATIENT,,,423,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101343,CDM,,OUTPATIENT,,,492,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101354,CDM,,OUTPATIENT,,,235.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101359,CDM,,OUTPATIENT,,,127.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101203,CDM,,OUTPATIENT,,,900,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101303,CDM,,OUTPATIENT,,,900,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101317,CDM,,OUTPATIENT,,,310.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101318,CDM,,OUTPATIENT,,,310.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101319,CDM,,OUTPATIENT,,,335.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101326,CDM,,OUTPATIENT,,,1222.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101356,CDM,,OUTPATIENT,,,303,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101358,CDM,,OUTPATIENT,,,474,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101437,CDM,,OUTPATIENT,,,285,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101443,CDM,,OUTPATIENT,,,138.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101484,CDM,,OUTPATIENT,,,114.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101492,CDM,,OUTPATIENT,,,223.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101494,CDM,,OUTPATIENT,,,279,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101545,CDM,,OUTPATIENT,,,1599,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101546,CDM,,OUTPATIENT,,,1917,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101549,CDM,,OUTPATIENT,,,1173,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101550,CDM,,OUTPATIENT,,,165,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101559,CDM,,OUTPATIENT,,,240,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101560,CDM,,OUTPATIENT,,,1437,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101561,CDM,,OUTPATIENT,,,5304,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101562,CDM,,OUTPATIENT,,,336,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101569,CDM,,OUTPATIENT,,,29.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101579,CDM,,OUTPATIENT,,,23.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101581,CDM,,OUTPATIENT,,,69.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101582,CDM,,OUTPATIENT,,,25.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101584,CDM,,OUTPATIENT,,,37.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101585,CDM,,OUTPATIENT,,,840,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101587,CDM,,OUTPATIENT,,,703.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101592,CDM,,OUTPATIENT,,,900,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101677,CDM,,OUTPATIENT,,,265.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101683,CDM,,OUTPATIENT,,,129.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101684,CDM,,OUTPATIENT,,,139.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101697,CDM,,OUTPATIENT,,,139.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101698,CDM,,OUTPATIENT,,,26.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101715,CDM,,OUTPATIENT,,,26.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101716,CDM,,OUTPATIENT,,,26.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101717,CDM,,OUTPATIENT,,,26.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101718,CDM,,OUTPATIENT,,,264.18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101765,CDM,,OUTPATIENT,,,9.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101766,CDM,,OUTPATIENT,,,42.27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101767,CDM,,OUTPATIENT,,,117.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101768,CDM,,OUTPATIENT,,,108.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101769,CDM,,OUTPATIENT,,,106.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101771,CDM,,OUTPATIENT,,,112.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101772,CDM,,OUTPATIENT,,,118.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101773,CDM,,OUTPATIENT,,,110.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101774,CDM,,OUTPATIENT,,,125.31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101777,CDM,,OUTPATIENT,,,579,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101778,CDM,,OUTPATIENT,,,777,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101781,CDM,,OUTPATIENT,,,17.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101794,CDM,,OUTPATIENT,,,18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101795,CDM,,OUTPATIENT,,,70.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101799,CDM,,OUTPATIENT,,,228,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101803,CDM,,OUTPATIENT,,,3.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101804,CDM,,OUTPATIENT,,,66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101819,CDM,,OUTPATIENT,,,18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101820,CDM,,OUTPATIENT,,,18.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
LOCAL ANES SUPPLY,,,370,RC,801004,CDM,,OUTPATIENT,,,202,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
M0243 INTRAVENOUS INFUSION MAB CHARGE,,,771,RC,M0243,CDM,,OUTPATIENT,,,901,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MAC/IV SED SUPPLY,,,370,RC,801000,CDM,,OUTPATIENT,,,310,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MDI SPACER SUPPLIES,,,270,RC,150805,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102346,CDM,,OUTPATIENT,,,2985,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102347,CDM,,OUTPATIENT,,,402,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - INTRAOCULAR LENSES,,,276,RC,62102348,CDM,,OUTPATIENT,,,1416,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041000,CDM,,OUTPATIENT,,,161.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041009,CDM,,OUTPATIENT,,,134.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041010,CDM,,OUTPATIENT,,,116.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041011,CDM,,OUTPATIENT,,,116.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041013,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041014,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041016,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041018,CDM,,OUTPATIENT,,,86.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041019,CDM,,OUTPATIENT,,,86.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041020,CDM,,OUTPATIENT,,,86.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041021,CDM,,OUTPATIENT,,,86.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041022,CDM,,OUTPATIENT,,,93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041023,CDM,,OUTPATIENT,,,86.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041024,CDM,,OUTPATIENT,,,86.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041025,CDM,,OUTPATIENT,,,79.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041026,CDM,,OUTPATIENT,,,79.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041027,CDM,,OUTPATIENT,,,38.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041028,CDM,,OUTPATIENT,,,73.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041029,CDM,,OUTPATIENT,,,131.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041030,CDM,,OUTPATIENT,,,197.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041031,CDM,,OUTPATIENT,,,197.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041036,CDM,,OUTPATIENT,,,25.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041037,CDM,,OUTPATIENT,,,25.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041038,CDM,,OUTPATIENT,,,223.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041039,CDM,,OUTPATIENT,,,223.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041040,CDM,,OUTPATIENT,,,223.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041041,CDM,,OUTPATIENT,,,223.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041042,CDM,,OUTPATIENT,,,156.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041043,CDM,,OUTPATIENT,,,243.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041044,CDM,,OUTPATIENT,,,243.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041045,CDM,,OUTPATIENT,,,287.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041046,CDM,,OUTPATIENT,,,338.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041047,CDM,,OUTPATIENT,,,338.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041048,CDM,,OUTPATIENT,,,338.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041049,CDM,,OUTPATIENT,,,338.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041050,CDM,,OUTPATIENT,,,338.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041051,CDM,,OUTPATIENT,,,162,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041052,CDM,,OUTPATIENT,,,162,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041053,CDM,,OUTPATIENT,,,162,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041054,CDM,,OUTPATIENT,,,234.21,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041058,CDM,,OUTPATIENT,,,223.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801046,CDM,,OUTPATIENT,,,35.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101001,CDM,,OUTPATIENT,,,12.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101002,CDM,,OUTPATIENT,,,6.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101003,CDM,,OUTPATIENT,,,4.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101006,CDM,,OUTPATIENT,,,18.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101007,CDM,,OUTPATIENT,,,15.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101008,CDM,,OUTPATIENT,,,14.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101009,CDM,,OUTPATIENT,,,5.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101010,CDM,,OUTPATIENT,,,20.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101011,CDM,,OUTPATIENT,,,8.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101023,CDM,,OUTPATIENT,,,13.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101044,CDM,,OUTPATIENT,,,90.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101047,CDM,,OUTPATIENT,,,12.18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101050,CDM,,OUTPATIENT,,,30.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101054,CDM,,OUTPATIENT,,,16.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101062,CDM,,OUTPATIENT,,,12.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101065,CDM,,OUTPATIENT,,,8.37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101066,CDM,,OUTPATIENT,,,6.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101069,CDM,,OUTPATIENT,,,112.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101099,CDM,,OUTPATIENT,,,64.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101118,CDM,,OUTPATIENT,,,28.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101139,CDM,,OUTPATIENT,,,95.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101198,CDM,,OUTPATIENT,,,23.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101588,CDM,,OUTPATIENT,,,3105,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101589,CDM,,OUTPATIENT,,,2538,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101593,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101595,CDM,,OUTPATIENT,,,938.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101604,CDM,,OUTPATIENT,,,81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101615,CDM,,OUTPATIENT,,,1704,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101630,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101639,CDM,,OUTPATIENT,,,263.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101641,CDM,,OUTPATIENT,,,263.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101642,CDM,,OUTPATIENT,,,1794,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101643,CDM,,OUTPATIENT,,,193.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101645,CDM,,OUTPATIENT,,,193.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101647,CDM,,OUTPATIENT,,,223.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101649,CDM,,OUTPATIENT,,,99.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101651,CDM,,OUTPATIENT,,,93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101653,CDM,,OUTPATIENT,,,141.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101655,CDM,,OUTPATIENT,,,93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101657,CDM,,OUTPATIENT,,,110.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101660,CDM,,OUTPATIENT,,,135,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701208,CDM,,OUTPATIENT,,,36.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701209,CDM,,OUTPATIENT,,,46.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701241,CDM,,OUTPATIENT,,,31.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701252,CDM,,OUTPATIENT,,,102.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701555,CDM,,OUTPATIENT,,,13.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701556,CDM,,OUTPATIENT,,,15.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701808,CDM,,OUTPATIENT,,,41.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701905,CDM,,OUTPATIENT,,,3.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701906,CDM,,OUTPATIENT,,,3.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701908,CDM,,OUTPATIENT,,,4.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701909,CDM,,OUTPATIENT,,,4.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701910,CDM,,OUTPATIENT,,,6.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701911,CDM,,OUTPATIENT,,,4.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701912,CDM,,OUTPATIENT,,,3.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701913,CDM,,OUTPATIENT,,,4.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701914,CDM,,OUTPATIENT,,,7.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701915,CDM,,OUTPATIENT,,,6.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701916,CDM,,OUTPATIENT,,,5.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701917,CDM,,OUTPATIENT,,,6.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701918,CDM,,OUTPATIENT,,,7.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701919,CDM,,OUTPATIENT,,,7.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701920,CDM,,OUTPATIENT,,,7.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701921,CDM,,OUTPATIENT,,,6.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701922,CDM,,OUTPATIENT,,,7.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701923,CDM,,OUTPATIENT,,,6.21,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701924,CDM,,OUTPATIENT,,,6.21,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701929,CDM,,OUTPATIENT,,,14.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701930,CDM,,OUTPATIENT,,,14.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701931,CDM,,OUTPATIENT,,,6.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701934,CDM,,OUTPATIENT,,,3.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701935,CDM,,OUTPATIENT,,,3.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701936,CDM,,OUTPATIENT,,,3.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701937,CDM,,OUTPATIENT,,,116.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701938,CDM,,OUTPATIENT,,,87.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701939,CDM,,OUTPATIENT,,,7.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701940,CDM,,OUTPATIENT,,,115.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701941,CDM,,OUTPATIENT,,,87.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701942,CDM,,OUTPATIENT,,,115.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701943,CDM,,OUTPATIENT,,,87.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701944,CDM,,OUTPATIENT,,,107.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER SUPPLIES / DEVICES,,,279,RC,75041175,CDM,,OUTPATIENT,,,12.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102554,CDM,,OUTPATIENT,,,267.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102592,CDM,,OUTPATIENT,,,124.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62102599,CDM,,OUTPATIENT,,,378.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,62301002,CDM,,OUTPATIENT,,,213.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101409,CDM,,OUTPATIENT,,,31.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101410,CDM,,OUTPATIENT,,,31.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101411,CDM,,OUTPATIENT,,,31.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101412,CDM,,OUTPATIENT,,,31.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101440,CDM,,OUTPATIENT,,,432,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101441,CDM,,OUTPATIENT,,,42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101442,CDM,,OUTPATIENT,,,657,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101445,CDM,,OUTPATIENT,,,229.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101447,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101448,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101449,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101450,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101451,CDM,,OUTPATIENT,,,27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101452,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101453,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101454,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101455,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101456,CDM,,OUTPATIENT,,,30,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101457,CDM,,OUTPATIENT,,,54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101460,CDM,,OUTPATIENT,,,450,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101461,CDM,,OUTPATIENT,,,660,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101462,CDM,,OUTPATIENT,,,606,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101463,CDM,,OUTPATIENT,,,594,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101464,CDM,,OUTPATIENT,,,483,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101465,CDM,,OUTPATIENT,,,849,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101481,CDM,,OUTPATIENT,,,546,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101482,CDM,,OUTPATIENT,,,510,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101483,CDM,,OUTPATIENT,,,120,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101485,CDM,,OUTPATIENT,,,120,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101486,CDM,,OUTPATIENT,,,111.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101487,CDM,,OUTPATIENT,,,119.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101488,CDM,,OUTPATIENT,,,102.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101489,CDM,,OUTPATIENT,,,98.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101490,CDM,,OUTPATIENT,,,396,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101496,CDM,,OUTPATIENT,,,16.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101522,CDM,,OUTPATIENT,,,33.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101523,CDM,,OUTPATIENT,,,33.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101536,CDM,,OUTPATIENT,,,240,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101538,CDM,,OUTPATIENT,,,114.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101539,CDM,,OUTPATIENT,,,411,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101541,CDM,,OUTPATIENT,,,216,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101542,CDM,,OUTPATIENT,,,360,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101544,CDM,,OUTPATIENT,,,444,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101547,CDM,,OUTPATIENT,,,1008,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101548,CDM,,OUTPATIENT,,,507,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101552,CDM,,OUTPATIENT,,,552,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101553,CDM,,OUTPATIENT,,,507,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101554,CDM,,OUTPATIENT,,,77.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101555,CDM,,OUTPATIENT,,,507,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101556,CDM,,OUTPATIENT,,,468,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101557,CDM,,OUTPATIENT,,,468,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101558,CDM,,OUTPATIENT,,,468,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101563,CDM,,OUTPATIENT,,,303,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101565,CDM,,OUTPATIENT,,,303,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101566,CDM,,OUTPATIENT,,,603,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101567,CDM,,OUTPATIENT,,,603,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101570,CDM,,OUTPATIENT,,,74.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101571,CDM,,OUTPATIENT,,,101.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101572,CDM,,OUTPATIENT,,,107.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101573,CDM,,OUTPATIENT,,,138.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101574,CDM,,OUTPATIENT,,,138.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101575,CDM,,OUTPATIENT,,,201,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101576,CDM,,OUTPATIENT,,,33.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101577,CDM,,OUTPATIENT,,,16.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106207,CDM,,OUTPATIENT,,,8649,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106210,CDM,,OUTPATIENT,,,633.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109204,CDM,,OUTPATIENT,,,831,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109205,CDM,,OUTPATIENT,,,462,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109206,CDM,,OUTPATIENT,,,5787,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109207,CDM,,OUTPATIENT,,,357,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109208,CDM,,OUTPATIENT,,,366,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109209,CDM,,OUTPATIENT,,,507,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109210,CDM,,OUTPATIENT,,,4539,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109211,CDM,,OUTPATIENT,,,4851,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109212,CDM,,OUTPATIENT,,,2895,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109213,CDM,,OUTPATIENT,,,5346,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109214,CDM,,OUTPATIENT,,,18123,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109215,CDM,,OUTPATIENT,,,23907,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109216,CDM,,OUTPATIENT,,,10530,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109217,CDM,,OUTPATIENT,,,12993,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109218,CDM,,OUTPATIENT,,,2790,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109219,CDM,,OUTPATIENT,,,5832,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109220,CDM,,OUTPATIENT,,,8547,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109221,CDM,,OUTPATIENT,,,6300,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109222,CDM,,OUTPATIENT,,,19959,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109223,CDM,,OUTPATIENT,,,5934,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109224,CDM,,OUTPATIENT,,,11484,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109225,CDM,,OUTPATIENT,,,19935,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109226,CDM,,OUTPATIENT,,,10686,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109227,CDM,,OUTPATIENT,,,5826,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109230,CDM,,OUTPATIENT,,,1812,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109232,CDM,,OUTPATIENT,,,4770,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109233,CDM,,OUTPATIENT,,,7245,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109234,CDM,,OUTPATIENT,,,570,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109241,CDM,,OUTPATIENT,,,5061,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109243,CDM,,OUTPATIENT,,,330,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109247,CDM,,OUTPATIENT,,,90,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62109248,CDM,,OUTPATIENT,,,5232,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62301025,CDM,,OUTPATIENT,,,78.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421003,CDM,,OUTPATIENT,,,1650,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421004,CDM,,OUTPATIENT,,,1650,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,70421005,CDM,,OUTPATIENT,,,1650,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,72101016,CDM,,OUTPATIENT,,,656.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,93701207,CDM,,OUTPATIENT,,,250.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040151,CDM,,OUTPATIENT,,,592.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040152,CDM,,OUTPATIENT,,,361.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040153,CDM,,OUTPATIENT,,,331.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040155,CDM,,OUTPATIENT,,,93.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040162,CDM,,OUTPATIENT,,,454.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040164,CDM,,OUTPATIENT,,,1014.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,7040165,CDM,,OUTPATIENT,,,340.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
NUCLEAR MEDICINE - RADIOPHARM DIAGNOSTIC,,,343,RC,70411000,CDM,,OUTPATIENT,,,840,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040168,CDM,,OUTPATIENT,,,1941.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER IMAGING - ULTRASOUND,,,402,RC,7040169,CDM,,OUTPATIENT,,,1941.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5002,CDM,,OUTPATIENT,,,122.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5003,CDM,,OUTPATIENT,,,126.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
OTHER PROFESSIONAL FEES,,,969,RC,5020,CDM,,OUTPATIENT,,,78.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101360,CDM,,OUTPATIENT,,,450,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101361,CDM,,OUTPATIENT,,,118.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101362,CDM,,OUTPATIENT,,,111.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101364,CDM,,OUTPATIENT,,,107.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101402,CDM,,OUTPATIENT,,,62.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101403,CDM,,OUTPATIENT,,,62.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101404,CDM,,OUTPATIENT,,,62.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101405,CDM,,OUTPATIENT,,,62.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101406,CDM,,OUTPATIENT,,,62.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101407,CDM,,OUTPATIENT,,,31.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101408,CDM,,OUTPATIENT,,,31.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102512,CDM,,OUTPATIENT,,,798,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102513,CDM,,OUTPATIENT,,,63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102514,CDM,,OUTPATIENT,,,2228.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102515,CDM,,OUTPATIENT,,,344.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102516,CDM,,OUTPATIENT,,,249.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102518,CDM,,OUTPATIENT,,,1644.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102519,CDM,,OUTPATIENT,,,541.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102520,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102522,CDM,,OUTPATIENT,,,537,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102523,CDM,,OUTPATIENT,,,537,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102524,CDM,,OUTPATIENT,,,537,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102525,CDM,,OUTPATIENT,,,648,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102526,CDM,,OUTPATIENT,,,1371,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102528,CDM,,OUTPATIENT,,,7986,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102529,CDM,,OUTPATIENT,,,627,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102530,CDM,,OUTPATIENT,,,627,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102531,CDM,,OUTPATIENT,,,627,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102532,CDM,,OUTPATIENT,,,7635,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102533,CDM,,OUTPATIENT,,,4272,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102535,CDM,,OUTPATIENT,,,9810,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102536,CDM,,OUTPATIENT,,,15219,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102537,CDM,,OUTPATIENT,,,4887,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102538,CDM,,OUTPATIENT,,,15888,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102539,CDM,,OUTPATIENT,,,1524,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102540,CDM,,OUTPATIENT,,,7635,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102541,CDM,,OUTPATIENT,,,627,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102542,CDM,,OUTPATIENT,,,627,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102543,CDM,,OUTPATIENT,,,4272,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102544,CDM,,OUTPATIENT,,,315,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102545,CDM,,OUTPATIENT,,,9810,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102546,CDM,,OUTPATIENT,,,9744,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102547,CDM,,OUTPATIENT,,,627,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102548,CDM,,OUTPATIENT,,,9810,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102550,CDM,,OUTPATIENT,,,12120,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102551,CDM,,OUTPATIENT,,,627,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102553,CDM,,OUTPATIENT,,,4232.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102563,CDM,,OUTPATIENT,,,303,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102568,CDM,,OUTPATIENT,,,1065,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102571,CDM,,OUTPATIENT,,,1260,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102574,CDM,,OUTPATIENT,,,1485,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102593,CDM,,OUTPATIENT,,,1275,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102618,CDM,,OUTPATIENT,,,246,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102620,CDM,,OUTPATIENT,,,462,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102621,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102630,CDM,,OUTPATIENT,,,76.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102653,CDM,,OUTPATIENT,,,1200,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103037,CDM,,OUTPATIENT,,,1485,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103146,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103189,CDM,,OUTPATIENT,,,246,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103249,CDM,,OUTPATIENT,,,3051,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103289,CDM,,OUTPATIENT,,,246,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103290,CDM,,OUTPATIENT,,,462,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103291,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103358,CDM,,OUTPATIENT,,,165,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103413,CDM,,OUTPATIENT,,,233.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103432,CDM,,OUTPATIENT,,,525,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62103433,CDM,,OUTPATIENT,,,525,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106163,CDM,,OUTPATIENT,,,4254,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106168,CDM,,OUTPATIENT,,,1215,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106171,CDM,,OUTPATIENT,,,108,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106174,CDM,,OUTPATIENT,,,1125,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106178,CDM,,OUTPATIENT,,,1081.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106179,CDM,,OUTPATIENT,,,990,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62106199,CDM,,OUTPATIENT,,,5.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102401,CDM,,OUTPATIENT,,,630,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102402,CDM,,OUTPATIENT,,,2193.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102403,CDM,,OUTPATIENT,,,5340,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102410,CDM,,OUTPATIENT,,,1500,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102412,CDM,,OUTPATIENT,,,465,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102417,CDM,,OUTPATIENT,,,35.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102432,CDM,,OUTPATIENT,,,2547,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102434,CDM,,OUTPATIENT,,,117,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102439,CDM,,OUTPATIENT,,,2841,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102441,CDM,,OUTPATIENT,,,168,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102442,CDM,,OUTPATIENT,,,336,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102443,CDM,,OUTPATIENT,,,537,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102444,CDM,,OUTPATIENT,,,450,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102445,CDM,,OUTPATIENT,,,600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102446,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102447,CDM,,OUTPATIENT,,,2580,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102448,CDM,,OUTPATIENT,,,7089,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102449,CDM,,OUTPATIENT,,,113.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102453,CDM,,OUTPATIENT,,,720,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102454,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102455,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102456,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102457,CDM,,OUTPATIENT,,,12900,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102458,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102459,CDM,,OUTPATIENT,,,7230,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102460,CDM,,OUTPATIENT,,,8737.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102461,CDM,,OUTPATIENT,,,562.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102462,CDM,,OUTPATIENT,,,7872,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102463,CDM,,OUTPATIENT,,,2677.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102464,CDM,,OUTPATIENT,,,787.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102465,CDM,,OUTPATIENT,,,611.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102466,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102467,CDM,,OUTPATIENT,,,4634.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102468,CDM,,OUTPATIENT,,,749.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102471,CDM,,OUTPATIENT,,,6705,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102472,CDM,,OUTPATIENT,,,1102.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102474,CDM,,OUTPATIENT,,,9495,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102475,CDM,,OUTPATIENT,,,2085.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102476,CDM,,OUTPATIENT,,,321.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102478,CDM,,OUTPATIENT,,,336,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102480,CDM,,OUTPATIENT,,,6367.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102481,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102482,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102483,CDM,,OUTPATIENT,,,3551.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102484,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102486,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102487,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102490,CDM,,OUTPATIENT,,,4349.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102491,CDM,,OUTPATIENT,,,443.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102492,CDM,,OUTPATIENT,,,575.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102493,CDM,,OUTPATIENT,,,660,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102494,CDM,,OUTPATIENT,,,1071,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102495,CDM,,OUTPATIENT,,,331.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102496,CDM,,OUTPATIENT,,,77.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102497,CDM,,OUTPATIENT,,,4884.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102498,CDM,,OUTPATIENT,,,3427.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102499,CDM,,OUTPATIENT,,,7144.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102500,CDM,,OUTPATIENT,,,1728,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102501,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102502,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102503,CDM,,OUTPATIENT,,,621.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102507,CDM,,OUTPATIENT,,,4515,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102509,CDM,,OUTPATIENT,,,609,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102511,CDM,,OUTPATIENT,,,627,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101752,CDM,,OUTPATIENT,,,67.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101753,CDM,,OUTPATIENT,,,67.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101754,CDM,,OUTPATIENT,,,67.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101755,CDM,,OUTPATIENT,,,410.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101756,CDM,,OUTPATIENT,,,410.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101757,CDM,,OUTPATIENT,,,410.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101758,CDM,,OUTPATIENT,,,410.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101776,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101782,CDM,,OUTPATIENT,,,23.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101793,CDM,,OUTPATIENT,,,22.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101797,CDM,,OUTPATIENT,,,107.97,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101798,CDM,,OUTPATIENT,,,1347,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101801,CDM,,OUTPATIENT,,,1284,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101806,CDM,,OUTPATIENT,,,11.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101809,CDM,,OUTPATIENT,,,513,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101821,CDM,,OUTPATIENT,,,18.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101822,CDM,,OUTPATIENT,,,3039,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101875,CDM,,OUTPATIENT,,,489.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101907,CDM,,OUTPATIENT,,,3069,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101908,CDM,,OUTPATIENT,,,5403,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101911,CDM,,OUTPATIENT,,,83.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101918,CDM,,OUTPATIENT,,,1410,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101920,CDM,,OUTPATIENT,,,3816,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101921,CDM,,OUTPATIENT,,,6735,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101925,CDM,,OUTPATIENT,,,239.43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101929,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101932,CDM,,OUTPATIENT,,,4500,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101939,CDM,,OUTPATIENT,,,54.18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101940,CDM,,OUTPATIENT,,,54.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101941,CDM,,OUTPATIENT,,,53.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101945,CDM,,OUTPATIENT,,,24.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101947,CDM,,OUTPATIENT,,,732,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101948,CDM,,OUTPATIENT,,,50.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102018,CDM,,OUTPATIENT,,,465,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102019,CDM,,OUTPATIENT,,,390,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102076,CDM,,OUTPATIENT,,,576,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102077,CDM,,OUTPATIENT,,,213,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102078,CDM,,OUTPATIENT,,,213,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102079,CDM,,OUTPATIENT,,,213,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102080,CDM,,OUTPATIENT,,,213,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102081,CDM,,OUTPATIENT,,,213,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102082,CDM,,OUTPATIENT,,,213,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102083,CDM,,OUTPATIENT,,,213,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102084,CDM,,OUTPATIENT,,,213,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102085,CDM,,OUTPATIENT,,,576,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102086,CDM,,OUTPATIENT,,,576,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102087,CDM,,OUTPATIENT,,,576,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102088,CDM,,OUTPATIENT,,,576,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102089,CDM,,OUTPATIENT,,,576,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102090,CDM,,OUTPATIENT,,,162,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102186,CDM,,OUTPATIENT,,,324,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102202,CDM,,OUTPATIENT,,,125.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102203,CDM,,OUTPATIENT,,,125.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102223,CDM,,OUTPATIENT,,,611.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102253,CDM,,OUTPATIENT,,,515.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102257,CDM,,OUTPATIENT,,,6190.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102258,CDM,,OUTPATIENT,,,3357.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102388,CDM,,OUTPATIENT,,,48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102389,CDM,,OUTPATIENT,,,150,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102390,CDM,,OUTPATIENT,,,1275,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102394,CDM,,OUTPATIENT,,,231,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102395,CDM,,OUTPATIENT,,,3820.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102397,CDM,,OUTPATIENT,,,166.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62102400,CDM,,OUTPATIENT,,,2909.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040140,CDM,,OUTPATIENT,,,79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040143,CDM,,OUTPATIENT,,,50,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040145,CDM,,OUTPATIENT,,,99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040146,CDM,,OUTPATIENT,,,121,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040150,CDM,,OUTPATIENT,,,99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040156,CDM,,OUTPATIENT,,,160,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040157,CDM,,OUTPATIENT,,,160,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040158,CDM,,OUTPATIENT,,,160,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040163,CDM,,OUTPATIENT,,,25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040166,CDM,,OUTPATIENT,,,132,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040167,CDM,,OUTPATIENT,,,29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801002,CDM,,OUTPATIENT,,,1068.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801017,CDM,,OUTPATIENT,,,7.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801026,CDM,,OUTPATIENT,,,3.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,60801041,CDM,,OUTPATIENT,,,78.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101662,CDM,,OUTPATIENT,,,118.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101663,CDM,,OUTPATIENT,,,93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101664,CDM,,OUTPATIENT,,,99.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101665,CDM,,OUTPATIENT,,,200.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101675,CDM,,OUTPATIENT,,,77.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101678,CDM,,OUTPATIENT,,,138,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101679,CDM,,OUTPATIENT,,,210,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101680,CDM,,OUTPATIENT,,,213,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101681,CDM,,OUTPATIENT,,,222,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101682,CDM,,OUTPATIENT,,,154.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101685,CDM,,OUTPATIENT,,,46.83,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101699,CDM,,OUTPATIENT,,,30.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101700,CDM,,OUTPATIENT,,,16.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101706,CDM,,OUTPATIENT,,,750,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101707,CDM,,OUTPATIENT,,,750,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101708,CDM,,OUTPATIENT,,,810,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101709,CDM,,OUTPATIENT,,,555,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101710,CDM,,OUTPATIENT,,,264.18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101711,CDM,,OUTPATIENT,,,264.18,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101713,CDM,,OUTPATIENT,,,303.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101714,CDM,,OUTPATIENT,,,303.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101719,CDM,,OUTPATIENT,,,2085.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101720,CDM,,OUTPATIENT,,,2228.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101721,CDM,,OUTPATIENT,,,2838.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101722,CDM,,OUTPATIENT,,,3021.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101723,CDM,,OUTPATIENT,,,1556.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101724,CDM,,OUTPATIENT,,,2626.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101725,CDM,,OUTPATIENT,,,2838.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101726,CDM,,OUTPATIENT,,,3021.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101727,CDM,,OUTPATIENT,,,198.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101730,CDM,,OUTPATIENT,,,198.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101734,CDM,,OUTPATIENT,,,377.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101735,CDM,,OUTPATIENT,,,321.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101736,CDM,,OUTPATIENT,,,321.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101737,CDM,,OUTPATIENT,,,321.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101738,CDM,,OUTPATIENT,,,321.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101739,CDM,,OUTPATIENT,,,377.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101740,CDM,,OUTPATIENT,,,377.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101741,CDM,,OUTPATIENT,,,410.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101742,CDM,,OUTPATIENT,,,410.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101743,CDM,,OUTPATIENT,,,344.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101744,CDM,,OUTPATIENT,,,344.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101745,CDM,,OUTPATIENT,,,344.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101746,CDM,,OUTPATIENT,,,410.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101747,CDM,,OUTPATIENT,,,410.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101748,CDM,,OUTPATIENT,,,67.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101749,CDM,,OUTPATIENT,,,67.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101750,CDM,,OUTPATIENT,,,67.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - OTHER IMPLANTS,,,278,RC,62101751,CDM,,OUTPATIENT,,,67.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041064,CDM,,OUTPATIENT,,,161.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041065,CDM,,OUTPATIENT,,,65.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041066,CDM,,OUTPATIENT,,,43.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041067,CDM,,OUTPATIENT,,,338.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041075,CDM,,OUTPATIENT,,,400.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041084,CDM,,OUTPATIENT,,,10.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041100,CDM,,OUTPATIENT,,,416.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041101,CDM,,OUTPATIENT,,,212.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041109,CDM,,OUTPATIENT,,,291.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041118,CDM,,OUTPATIENT,,,25.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041120,CDM,,OUTPATIENT,,,27.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041121,CDM,,OUTPATIENT,,,223.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041122,CDM,,OUTPATIENT,,,223.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041125,CDM,,OUTPATIENT,,,223.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041126,CDM,,OUTPATIENT,,,223.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041162,CDM,,OUTPATIENT,,,255.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041170,CDM,,OUTPATIENT,,,167.67,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041179,CDM,,OUTPATIENT,,,33.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701138,CDM,,OUTPATIENT,,,77.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701139,CDM,,OUTPATIENT,,,77.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701140,CDM,,OUTPATIENT,,,124.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701141,CDM,,OUTPATIENT,,,77.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701142,CDM,,OUTPATIENT,,,103.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701143,CDM,,OUTPATIENT,,,77.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701144,CDM,,OUTPATIENT,,,77.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701145,CDM,,OUTPATIENT,,,77.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701146,CDM,,OUTPATIENT,,,77.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701147,CDM,,OUTPATIENT,,,103.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701161,CDM,,OUTPATIENT,,,21.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701162,CDM,,OUTPATIENT,,,21.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701163,CDM,,OUTPATIENT,,,28.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701164,CDM,,OUTPATIENT,,,19.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701165,CDM,,OUTPATIENT,,,21.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701166,CDM,,OUTPATIENT,,,20.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701168,CDM,,OUTPATIENT,,,21.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701169,CDM,,OUTPATIENT,,,41.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701269,CDM,,OUTPATIENT,,,14.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701273,CDM,,OUTPATIENT,,,24.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701274,CDM,,OUTPATIENT,,,24.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701275,CDM,,OUTPATIENT,,,24.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701470,CDM,,OUTPATIENT,,,25.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701471,CDM,,OUTPATIENT,,,21.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701472,CDM,,OUTPATIENT,,,81.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701473,CDM,,OUTPATIENT,,,67.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701474,CDM,,OUTPATIENT,,,49.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701475,CDM,,OUTPATIENT,,,45.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701476,CDM,,OUTPATIENT,,,35.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701759,CDM,,OUTPATIENT,,,142.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701760,CDM,,OUTPATIENT,,,142.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701761,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701762,CDM,,OUTPATIENT,,,58.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701773,CDM,,OUTPATIENT,,,115.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701774,CDM,,OUTPATIENT,,,33.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701775,CDM,,OUTPATIENT,,,48.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93701789,CDM,,OUTPATIENT,,,44.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93702020,CDM,,OUTPATIENT,,,97.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,93790015,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,CDM,CDM,,OUTPATIENT,,,23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040131,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040134,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040135,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040136,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040137,CDM,,OUTPATIENT,,,22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,7040139,CDM,,OUTPATIENT,,,223,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102562,CDM,,OUTPATIENT,,,420,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102567,CDM,,OUTPATIENT,,,420,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102570,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102572,CDM,,OUTPATIENT,,,597,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102573,CDM,,OUTPATIENT,,,570,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102594,CDM,,OUTPATIENT,,,96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102595,CDM,,OUTPATIENT,,,358.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102600,CDM,,OUTPATIENT,,,11.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102602,CDM,,OUTPATIENT,,,198,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102604,CDM,,OUTPATIENT,,,198,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102605,CDM,,OUTPATIENT,,,96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102622,CDM,,OUTPATIENT,,,600,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102623,CDM,,OUTPATIENT,,,72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102627,CDM,,OUTPATIENT,,,552,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102636,CDM,,OUTPATIENT,,,4.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102637,CDM,,OUTPATIENT,,,715.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102642,CDM,,OUTPATIENT,,,6.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102643,CDM,,OUTPATIENT,,,14.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102646,CDM,,OUTPATIENT,,,112.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102648,CDM,,OUTPATIENT,,,96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102999,CDM,,OUTPATIENT,,,75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103016,CDM,,OUTPATIENT,,,1.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103026,CDM,,OUTPATIENT,,,705,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103034,CDM,,OUTPATIENT,,,906,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103035,CDM,,OUTPATIENT,,,657,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103040,CDM,,OUTPATIENT,,,96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103142,CDM,,OUTPATIENT,,,120,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103255,CDM,,OUTPATIENT,,,59.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103258,CDM,,OUTPATIENT,,,26.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103323,CDM,,OUTPATIENT,,,4.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62103387,CDM,,OUTPATIENT,,,8.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106164,CDM,,OUTPATIENT,,,800.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106165,CDM,,OUTPATIENT,,,703.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106169,CDM,,OUTPATIENT,,,480,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106177,CDM,,OUTPATIENT,,,834.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106180,CDM,,OUTPATIENT,,,75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106182,CDM,,OUTPATIENT,,,795,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106184,CDM,,OUTPATIENT,,,516,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106198,CDM,,OUTPATIENT,,,67.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62106209,CDM,,OUTPATIENT,,,1170,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109193,CDM,,OUTPATIENT,,,8.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109203,CDM,,OUTPATIENT,,,72.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109231,CDM,,OUTPATIENT,,,1350,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109235,CDM,,OUTPATIENT,,,90,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109237,CDM,,OUTPATIENT,,,780,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109238,CDM,,OUTPATIENT,,,1065,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109239,CDM,,OUTPATIENT,,,924,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62109269,CDM,,OUTPATIENT,,,81.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301085,CDM,,OUTPATIENT,,,182.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70301143,CDM,,OUTPATIENT,,,133.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401000,CDM,,OUTPATIENT,,,29.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401001,CDM,,OUTPATIENT,,,29.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401002,CDM,,OUTPATIENT,,,798,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401003,CDM,,OUTPATIENT,,,29.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401004,CDM,,OUTPATIENT,,,29.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401009,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70401023,CDM,,OUTPATIENT,,,584.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421000,CDM,,OUTPATIENT,,,16.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421002,CDM,,OUTPATIENT,,,18.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041059,CDM,,OUTPATIENT,,,227.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041060,CDM,,OUTPATIENT,,,217.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041061,CDM,,OUTPATIENT,,,287.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041062,CDM,,OUTPATIENT,,,255.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - PROSTHETIC / ORTHOTIC DEV.,,,274,RC,75041063,CDM,,OUTPATIENT,,,255.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102235,CDM,,OUTPATIENT,,,557.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102236,CDM,,OUTPATIENT,,,252.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102238,CDM,,OUTPATIENT,,,96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102242,CDM,,OUTPATIENT,,,23.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102251,CDM,,OUTPATIENT,,,60,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102252,CDM,,OUTPATIENT,,,178.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102259,CDM,,OUTPATIENT,,,47.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102349,CDM,,OUTPATIENT,,,54.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102350,CDM,,OUTPATIENT,,,63.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102351,CDM,,OUTPATIENT,,,21.12,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102355,CDM,,OUTPATIENT,,,5.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102356,CDM,,OUTPATIENT,,,742.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102357,CDM,,OUTPATIENT,,,3.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102358,CDM,,OUTPATIENT,,,4.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102359,CDM,,OUTPATIENT,,,5.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102360,CDM,,OUTPATIENT,,,3.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102361,CDM,,OUTPATIENT,,,5.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102362,CDM,,OUTPATIENT,,,3.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102363,CDM,,OUTPATIENT,,,4.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102364,CDM,,OUTPATIENT,,,18.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102367,CDM,,OUTPATIENT,,,3.27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102368,CDM,,OUTPATIENT,,,3.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102369,CDM,,OUTPATIENT,,,12.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102370,CDM,,OUTPATIENT,,,12.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102371,CDM,,OUTPATIENT,,,67.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102377,CDM,,OUTPATIENT,,,177,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102378,CDM,,OUTPATIENT,,,117,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102379,CDM,,OUTPATIENT,,,177,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102380,CDM,,OUTPATIENT,,,198,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102381,CDM,,OUTPATIENT,,,177,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102382,CDM,,OUTPATIENT,,,570,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102383,CDM,,OUTPATIENT,,,52.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102384,CDM,,OUTPATIENT,,,111.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102387,CDM,,OUTPATIENT,,,183,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102391,CDM,,OUTPATIENT,,,17.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102393,CDM,,OUTPATIENT,,,510,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102404,CDM,,OUTPATIENT,,,456.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102405,CDM,,OUTPATIENT,,,456.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102406,CDM,,OUTPATIENT,,,420,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102407,CDM,,OUTPATIENT,,,456.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102408,CDM,,OUTPATIENT,,,1725,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102409,CDM,,OUTPATIENT,,,1395,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102413,CDM,,OUTPATIENT,,,88.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102415,CDM,,OUTPATIENT,,,146.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102416,CDM,,OUTPATIENT,,,10500,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102418,CDM,,OUTPATIENT,,,83.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102431,CDM,,OUTPATIENT,,,885,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102440,CDM,,OUTPATIENT,,,318,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102450,CDM,,OUTPATIENT,,,249.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102451,CDM,,OUTPATIENT,,,1545,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102470,CDM,,OUTPATIENT,,,1500,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102473,CDM,,OUTPATIENT,,,810,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102477,CDM,,OUTPATIENT,,,810,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102479,CDM,,OUTPATIENT,,,75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102485,CDM,,OUTPATIENT,,,750,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102488,CDM,,OUTPATIENT,,,20343,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102489,CDM,,OUTPATIENT,,,8550,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102505,CDM,,OUTPATIENT,,,150,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102506,CDM,,OUTPATIENT,,,1164,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102510,CDM,,OUTPATIENT,,,51.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102527,CDM,,OUTPATIENT,,,1530,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102549,CDM,,OUTPATIENT,,,276,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102559,CDM,,OUTPATIENT,,,1515,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102561,CDM,,OUTPATIENT,,,198,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102119,CDM,,OUTPATIENT,,,5.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102120,CDM,,OUTPATIENT,,,6.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102121,CDM,,OUTPATIENT,,,24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102122,CDM,,OUTPATIENT,,,21.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102123,CDM,,OUTPATIENT,,,6.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102124,CDM,,OUTPATIENT,,,23.64,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102125,CDM,,OUTPATIENT,,,11.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102126,CDM,,OUTPATIENT,,,12.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102127,CDM,,OUTPATIENT,,,4.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102128,CDM,,OUTPATIENT,,,3.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102130,CDM,,OUTPATIENT,,,3.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102131,CDM,,OUTPATIENT,,,24.87,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102132,CDM,,OUTPATIENT,,,7.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102134,CDM,,OUTPATIENT,,,1587,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102135,CDM,,OUTPATIENT,,,1294.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102136,CDM,,OUTPATIENT,,,780,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102138,CDM,,OUTPATIENT,,,4.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102139,CDM,,OUTPATIENT,,,3.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102140,CDM,,OUTPATIENT,,,32.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102141,CDM,,OUTPATIENT,,,34.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102142,CDM,,OUTPATIENT,,,11.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102143,CDM,,OUTPATIENT,,,35.55,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102144,CDM,,OUTPATIENT,,,14.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102145,CDM,,OUTPATIENT,,,4.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102146,CDM,,OUTPATIENT,,,10.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102147,CDM,,OUTPATIENT,,,4.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102148,CDM,,OUTPATIENT,,,67.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102149,CDM,,OUTPATIENT,,,67.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102150,CDM,,OUTPATIENT,,,580.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102151,CDM,,OUTPATIENT,,,287.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102152,CDM,,OUTPATIENT,,,479.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102153,CDM,,OUTPATIENT,,,490.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102154,CDM,,OUTPATIENT,,,860.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102155,CDM,,OUTPATIENT,,,774.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102156,CDM,,OUTPATIENT,,,717,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102157,CDM,,OUTPATIENT,,,324.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102158,CDM,,OUTPATIENT,,,237,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102159,CDM,,OUTPATIENT,,,798.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102160,CDM,,OUTPATIENT,,,382.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102161,CDM,,OUTPATIENT,,,382.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102162,CDM,,OUTPATIENT,,,424.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102163,CDM,,OUTPATIENT,,,372.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102164,CDM,,OUTPATIENT,,,249.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102165,CDM,,OUTPATIENT,,,167.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102166,CDM,,OUTPATIENT,,,474.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102167,CDM,,OUTPATIENT,,,1808.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102169,CDM,,OUTPATIENT,,,8.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102176,CDM,,OUTPATIENT,,,96.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102180,CDM,,OUTPATIENT,,,137.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102181,CDM,,OUTPATIENT,,,32.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102184,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102185,CDM,,OUTPATIENT,,,195,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102200,CDM,,OUTPATIENT,,,35.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102201,CDM,,OUTPATIENT,,,8.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102214,CDM,,OUTPATIENT,,,4437.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102215,CDM,,OUTPATIENT,,,150,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102217,CDM,,OUTPATIENT,,,555,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102224,CDM,,OUTPATIENT,,,485.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102225,CDM,,OUTPATIENT,,,73.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102226,CDM,,OUTPATIENT,,,42.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102228,CDM,,OUTPATIENT,,,167.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102229,CDM,,OUTPATIENT,,,34.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102231,CDM,,OUTPATIENT,,,32.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102234,CDM,,OUTPATIENT,,,54.03,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101946,CDM,,OUTPATIENT,,,84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101973,CDM,,OUTPATIENT,,,54.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101974,CDM,,OUTPATIENT,,,39.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101975,CDM,,OUTPATIENT,,,49.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101976,CDM,,OUTPATIENT,,,52.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102008,CDM,,OUTPATIENT,,,135,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102009,CDM,,OUTPATIENT,,,194.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102010,CDM,,OUTPATIENT,,,168.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102011,CDM,,OUTPATIENT,,,166.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102012,CDM,,OUTPATIENT,,,255,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102013,CDM,,OUTPATIENT,,,204.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102014,CDM,,OUTPATIENT,,,109.83,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102015,CDM,,OUTPATIENT,,,208.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102016,CDM,,OUTPATIENT,,,106.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102020,CDM,,OUTPATIENT,,,10.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102021,CDM,,OUTPATIENT,,,5.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102022,CDM,,OUTPATIENT,,,5.97,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102023,CDM,,OUTPATIENT,,,7.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102024,CDM,,OUTPATIENT,,,3.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102025,CDM,,OUTPATIENT,,,35.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102026,CDM,,OUTPATIENT,,,3.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102027,CDM,,OUTPATIENT,,,5.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102028,CDM,,OUTPATIENT,,,3.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102029,CDM,,OUTPATIENT,,,5.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102030,CDM,,OUTPATIENT,,,5.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102031,CDM,,OUTPATIENT,,,10.26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102032,CDM,,OUTPATIENT,,,4.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102033,CDM,,OUTPATIENT,,,5.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102034,CDM,,OUTPATIENT,,,5.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102035,CDM,,OUTPATIENT,,,3.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102036,CDM,,OUTPATIENT,,,3.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102037,CDM,,OUTPATIENT,,,2.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102038,CDM,,OUTPATIENT,,,2.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102039,CDM,,OUTPATIENT,,,3.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102040,CDM,,OUTPATIENT,,,7.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102041,CDM,,OUTPATIENT,,,4.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102043,CDM,,OUTPATIENT,,,50.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102044,CDM,,OUTPATIENT,,,81.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102045,CDM,,OUTPATIENT,,,72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102046,CDM,,OUTPATIENT,,,111,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102048,CDM,,OUTPATIENT,,,98.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102049,CDM,,OUTPATIENT,,,43.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102050,CDM,,OUTPATIENT,,,119.67,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102051,CDM,,OUTPATIENT,,,142.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102052,CDM,,OUTPATIENT,,,43.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102053,CDM,,OUTPATIENT,,,135,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102054,CDM,,OUTPATIENT,,,142.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102055,CDM,,OUTPATIENT,,,60,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102056,CDM,,OUTPATIENT,,,150,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102057,CDM,,OUTPATIENT,,,105,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102058,CDM,,OUTPATIENT,,,120,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102059,CDM,,OUTPATIENT,,,7.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102060,CDM,,OUTPATIENT,,,3.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102061,CDM,,OUTPATIENT,,,77.43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102062,CDM,,OUTPATIENT,,,54.21,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102063,CDM,,OUTPATIENT,,,77.43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102064,CDM,,OUTPATIENT,,,77.43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102067,CDM,,OUTPATIENT,,,258,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102075,CDM,,OUTPATIENT,,,19.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102114,CDM,,OUTPATIENT,,,4.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102115,CDM,,OUTPATIENT,,,10.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102116,CDM,,OUTPATIENT,,,8.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102117,CDM,,OUTPATIENT,,,37.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62102118,CDM,,OUTPATIENT,,,142.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701011,CDM,,OUTPATIENT,,,9.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701012,CDM,,OUTPATIENT,,,32.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701013,CDM,,OUTPATIENT,,,4.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701014,CDM,,OUTPATIENT,,,4.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701017,CDM,,OUTPATIENT,,,5.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701018,CDM,,OUTPATIENT,,,5.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701019,CDM,,OUTPATIENT,,,5.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701020,CDM,,OUTPATIENT,,,5.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701021,CDM,,OUTPATIENT,,,5.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701026,CDM,,OUTPATIENT,,,1.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701087,CDM,,OUTPATIENT,,,806.97,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701148,CDM,,OUTPATIENT,,,90.33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701206,CDM,,OUTPATIENT,,,30.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701210,CDM,,OUTPATIENT,,,21.33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701211,CDM,,OUTPATIENT,,,21.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701212,CDM,,OUTPATIENT,,,21.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701214,CDM,,OUTPATIENT,,,31.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701215,CDM,,OUTPATIENT,,,3.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701216,CDM,,OUTPATIENT,,,24.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101852,CDM,,OUTPATIENT,,,17.43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101859,CDM,,OUTPATIENT,,,525,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101860,CDM,,OUTPATIENT,,,20.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101862,CDM,,OUTPATIENT,,,825,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101863,CDM,,OUTPATIENT,,,1785,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101867,CDM,,OUTPATIENT,,,31.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101872,CDM,,OUTPATIENT,,,7.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101874,CDM,,OUTPATIENT,,,171.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101876,CDM,,OUTPATIENT,,,18.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101877,CDM,,OUTPATIENT,,,7.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101878,CDM,,OUTPATIENT,,,5.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101879,CDM,,OUTPATIENT,,,61.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101880,CDM,,OUTPATIENT,,,50.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101881,CDM,,OUTPATIENT,,,7.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101882,CDM,,OUTPATIENT,,,6.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101883,CDM,,OUTPATIENT,,,66.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101884,CDM,,OUTPATIENT,,,12.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101885,CDM,,OUTPATIENT,,,6.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101886,CDM,,OUTPATIENT,,,28.26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101887,CDM,,OUTPATIENT,,,6.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101888,CDM,,OUTPATIENT,,,13.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101889,CDM,,OUTPATIENT,,,5.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101890,CDM,,OUTPATIENT,,,5.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101891,CDM,,OUTPATIENT,,,17.67,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101892,CDM,,OUTPATIENT,,,24.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101893,CDM,,OUTPATIENT,,,35.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101894,CDM,,OUTPATIENT,,,59.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101895,CDM,,OUTPATIENT,,,4.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101898,CDM,,OUTPATIENT,,,10.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101899,CDM,,OUTPATIENT,,,62.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101900,CDM,,OUTPATIENT,,,519.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101901,CDM,,OUTPATIENT,,,48.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101902,CDM,,OUTPATIENT,,,132.69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101903,CDM,,OUTPATIENT,,,63.93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101905,CDM,,OUTPATIENT,,,80.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101914,CDM,,OUTPATIENT,,,591,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101915,CDM,,OUTPATIENT,,,61.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101931,CDM,,OUTPATIENT,,,45.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101933,CDM,,OUTPATIENT,,,14.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101934,CDM,,OUTPATIENT,,,144,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101935,CDM,,OUTPATIENT,,,116.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101936,CDM,,OUTPATIENT,,,248.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101937,CDM,,OUTPATIENT,,,63.33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101938,CDM,,OUTPATIENT,,,64.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,62101944,CDM,,OUTPATIENT,,,18.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES CONTRACT/15 MIN,,,990,RC,7082020,CDM,,OUTPATIENT,,,27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106197,CDM,,OUTPATIENT,,,70.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MES OT CONTRACT,,,990,RC,7081030,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,,,401,RC,7047000,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG BILATERAL:REPORT,,,960,RC,7505078,CDM,,OUTPATIENT,,,64.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT,,,401,RC,7047001,CDM,,OUTPATIENT,,,52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG LEFT:REPORT,,,960,RC,7505079,CDM,,OUTPATIENT,,,64.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG BREAST TOMO 3D DIGITAL DIAG RIGHT:REPORT,,,960,RC,7505080,CDM,,OUTPATIENT,,,64.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MG DIAGNOSTIC DIGITAL BREAST TOMO PRO CHARGE,,,960,RC,G0279,CDM,,OUTPATIENT,,,65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MIRENA IUD,,,636,RC,J7298,CDM,,OUTPATIENT,,,1282,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 OT CONTRACT,,,990,RC,7081033,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 SPEECH CONTRACT,,,990,RC,7082021,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD 33 ST CONTRACT,,,444,RC,7082029,CDM,,OUTPATIENT,,,17.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MSAD OT CONTRACT,,,990,RC,7081029,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421007,CDM,,OUTPATIENT,,,450,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421008,CDM,,OUTPATIENT,,,35.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431000,CDM,,OUTPATIENT,,,150.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431009,CDM,,OUTPATIENT,,,150.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431010,CDM,,OUTPATIENT,,,150.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70431011,CDM,,OUTPATIENT,,,150.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101014,CDM,,OUTPATIENT,,,148.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101017,CDM,,OUTPATIENT,,,728.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101018,CDM,,OUTPATIENT,,,734.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101019,CDM,,OUTPATIENT,,,803.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101020,CDM,,OUTPATIENT,,,115.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101021,CDM,,OUTPATIENT,,,99.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101022,CDM,,OUTPATIENT,,,382.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101029,CDM,,OUTPATIENT,,,10.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101033,CDM,,OUTPATIENT,,,540,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101034,CDM,,OUTPATIENT,,,46.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101035,CDM,,OUTPATIENT,,,27.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101036,CDM,,OUTPATIENT,,,25.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101037,CDM,,OUTPATIENT,,,51.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101041,CDM,,OUTPATIENT,,,522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101042,CDM,,OUTPATIENT,,,522,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101043,CDM,,OUTPATIENT,,,465,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101045,CDM,,OUTPATIENT,,,135,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101049,CDM,,OUTPATIENT,,,69,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101051,CDM,,OUTPATIENT,,,309,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101056,CDM,,OUTPATIENT,,,282,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101057,CDM,,OUTPATIENT,,,562.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101060,CDM,,OUTPATIENT,,,648,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101061,CDM,,OUTPATIENT,,,330,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101065,CDM,,OUTPATIENT,,,369,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101067,CDM,,OUTPATIENT,,,166.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101068,CDM,,OUTPATIENT,,,270,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101071,CDM,,OUTPATIENT,,,57.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101072,CDM,,OUTPATIENT,,,99.54,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101077,CDM,,OUTPATIENT,,,184.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72101079,CDM,,OUTPATIENT,,,405,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201014,CDM,,OUTPATIENT,,,79.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72201015,CDM,,OUTPATIENT,,,32.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,72331001,CDM,,OUTPATIENT,,,124.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031001,CDM,,OUTPATIENT,,,93,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75031002,CDM,,OUTPATIENT,,,1590,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041074,CDM,,OUTPATIENT,,,40.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041129,CDM,,OUTPATIENT,,,525,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,75041143,CDM,,OUTPATIENT,,,255.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701003,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701006,CDM,,OUTPATIENT,,,22.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701007,CDM,,OUTPATIENT,,,21.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701008,CDM,,OUTPATIENT,,,21.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701009,CDM,,OUTPATIENT,,,21.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701010,CDM,,OUTPATIENT,,,19.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62301003,CDM,,OUTPATIENT,,,57.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301006,CDM,,OUTPATIENT,,,99.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301019,CDM,,OUTPATIENT,,,102,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,70301023,CDM,,OUTPATIENT,,,23.94,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101030,CDM,,OUTPATIENT,,,4800,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101066,CDM,,OUTPATIENT,,,103.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72101096,CDM,,OUTPATIENT,,,909,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,72381089,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041072,CDM,,OUTPATIENT,,,209.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041073,CDM,,OUTPATIENT,,,235.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,75041108,CDM,,OUTPATIENT,,,302.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701027,CDM,,OUTPATIENT,,,2.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701029,CDM,,OUTPATIENT,,,71.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701030,CDM,,OUTPATIENT,,,52.26,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701031,CDM,,OUTPATIENT,,,22.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701034,CDM,,OUTPATIENT,,,10.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701069,CDM,,OUTPATIENT,,,36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701119,CDM,,OUTPATIENT,,,181.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701136,CDM,,OUTPATIENT,,,100.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701171,CDM,,OUTPATIENT,,,40.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701195,CDM,,OUTPATIENT,,,80.88,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701205,CDM,,OUTPATIENT,,,46.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701286,CDM,,OUTPATIENT,,,10.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701287,CDM,,OUTPATIENT,,,10.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701299,CDM,,OUTPATIENT,,,80.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701306,CDM,,OUTPATIENT,,,50.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701344,CDM,,OUTPATIENT,,,21.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701345,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701347,CDM,,OUTPATIENT,,,17.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701367,CDM,,OUTPATIENT,,,7.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701374,CDM,,OUTPATIENT,,,41.22,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701376,CDM,,OUTPATIENT,,,62.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701395,CDM,,OUTPATIENT,,,590.37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701400,CDM,,OUTPATIENT,,,71.76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701408,CDM,,OUTPATIENT,,,162.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701450,CDM,,OUTPATIENT,,,37.77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701496,CDM,,OUTPATIENT,,,112.59,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701520,CDM,,OUTPATIENT,,,56.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701546,CDM,,OUTPATIENT,,,37.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701575,CDM,,OUTPATIENT,,,200.01,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701583,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701586,CDM,,OUTPATIENT,,,31.74,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701599,CDM,,OUTPATIENT,,,78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701606,CDM,,OUTPATIENT,,,89.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701656,CDM,,OUTPATIENT,,,2749.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701680,CDM,,OUTPATIENT,,,7.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701735,CDM,,OUTPATIENT,,,71.13,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701766,CDM,,OUTPATIENT,,,30.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701767,CDM,,OUTPATIENT,,,46.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701768,CDM,,OUTPATIENT,,,30.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701769,CDM,,OUTPATIENT,,,30.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701770,CDM,,OUTPATIENT,,,35.34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701771,CDM,,OUTPATIENT,,,30.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701777,CDM,,OUTPATIENT,,,90.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701782,CDM,,OUTPATIENT,,,38.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701838,CDM,,OUTPATIENT,,,50.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701925,CDM,,OUTPATIENT,,,28.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701946,CDM,,OUTPATIENT,,,29.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701948,CDM,,OUTPATIENT,,,27.39,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701959,CDM,,OUTPATIENT,,,70.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93701976,CDM,,OUTPATIENT,,,180.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702018,CDM,,OUTPATIENT,,,42.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,93702030,CDM,,OUTPATIENT,,,66.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,MISCSUP,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701833,CDM,,OUTPATIENT,,,7.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701834,CDM,,OUTPATIENT,,,7.41,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701835,CDM,,OUTPATIENT,,,3.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701836,CDM,,OUTPATIENT,,,6.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701837,CDM,,OUTPATIENT,,,6.99,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701839,CDM,,OUTPATIENT,,,11.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701840,CDM,,OUTPATIENT,,,2.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701841,CDM,,OUTPATIENT,,,3.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701842,CDM,,OUTPATIENT,,,4.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701843,CDM,,OUTPATIENT,,,5.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701844,CDM,,OUTPATIENT,,,10.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701845,CDM,,OUTPATIENT,,,10.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701888,CDM,,OUTPATIENT,,,183.6,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701889,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701891,CDM,,OUTPATIENT,,,66.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701892,CDM,,OUTPATIENT,,,115.29,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701893,CDM,,OUTPATIENT,,,75.09,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701895,CDM,,OUTPATIENT,,,178.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701927,CDM,,OUTPATIENT,,,16.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701933,CDM,,OUTPATIENT,,,9.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702023,CDM,,OUTPATIENT,,,275.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93702024,CDM,,OUTPATIENT,,,23.67,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,100000,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7030000,CDM,,OUTPATIENT,,,145,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040147,CDM,,OUTPATIENT,,,122,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040148,CDM,,OUTPATIENT,,,31,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040154,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,7040161,CDM,,OUTPATIENT,,,43,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,60801006,CDM,,OUTPATIENT,,,73.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101013,CDM,,OUTPATIENT,,,9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101186,CDM,,OUTPATIENT,,,20.97,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101316,CDM,,OUTPATIENT,,,310.95,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101712,CDM,,OUTPATIENT,,,249.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101802,CDM,,OUTPATIENT,,,154.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62101924,CDM,,OUTPATIENT,,,3630,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102113,CDM,,OUTPATIENT,,,3.72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102129,CDM,,OUTPATIENT,,,6.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102198,CDM,,OUTPATIENT,,,88.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102199,CDM,,OUTPATIENT,,,6190.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102210,CDM,,OUTPATIENT,,,507,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102211,CDM,,OUTPATIENT,,,288,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102212,CDM,,OUTPATIENT,,,60,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102232,CDM,,OUTPATIENT,,,178.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102392,CDM,,OUTPATIENT,,,341.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102452,CDM,,OUTPATIENT,,,303,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102517,CDM,,OUTPATIENT,,,585,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102565,CDM,,OUTPATIENT,,,456.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102596,CDM,,OUTPATIENT,,,195,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62102606,CDM,,OUTPATIENT,,,105,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103036,CDM,,OUTPATIENT,,,657,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103259,CDM,,OUTPATIENT,,,80.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103296,CDM,,OUTPATIENT,,,125.52,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103297,CDM,,OUTPATIENT,,,197.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103318,CDM,,OUTPATIENT,,,5088,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103319,CDM,,OUTPATIENT,,,2.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103320,CDM,,OUTPATIENT,,,5.37,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103321,CDM,,OUTPATIENT,,,4.77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103350,CDM,,OUTPATIENT,,,57.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103354,CDM,,OUTPATIENT,,,34.89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62103381,CDM,,OUTPATIENT,,,975,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106189,CDM,,OUTPATIENT,,,3.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62106195,CDM,,OUTPATIENT,,,3.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109196,CDM,,OUTPATIENT,,,56.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR SUPPLIES DEVICES,,,270,RC,62109270,CDM,,OUTPATIENT,,,303.27,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OBSERVATION,,,762,RC,Observation,CDM,,OUTPATIENT,,,72.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: PRIVATE,,,120,RC,LTCPRIV,CDM,,INPATIENT,,,467.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: SWING BED,,,120,RC,SwingBed,CDM,,INPATIENT,,,1077.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: TELEMETRY,,,210,RC,Telemetry,CDM,,INPATIENT,,,2643,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PROFESSIONAL FEES,,,960,RC,g0127,CDM,,OUTPATIENT,,,44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PSA SCREENING,,,300,RC,7010152,CDM,,OUTPATIENT,,,227.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE,,,780,RC,Q3014,CDM,,OUTPATIENT,,,56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701217,CDM,,OUTPATIENT,,,4.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701218,CDM,,OUTPATIENT,,,24.24,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701219,CDM,,OUTPATIENT,,,5.79,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701220,CDM,,OUTPATIENT,,,24.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701221,CDM,,OUTPATIENT,,,24.57,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701222,CDM,,OUTPATIENT,,,5.16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701223,CDM,,OUTPATIENT,,,10.77,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701224,CDM,,OUTPATIENT,,,6.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,70421006,CDM,,OUTPATIENT,,,450,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701225,CDM,,OUTPATIENT,,,6.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701226,CDM,,OUTPATIENT,,,10.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701227,CDM,,OUTPATIENT,,,22.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701228,CDM,,OUTPATIENT,,,72.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701229,CDM,,OUTPATIENT,,,31.56,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701230,CDM,,OUTPATIENT,,,4.92,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701231,CDM,,OUTPATIENT,,,22.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701253,CDM,,OUTPATIENT,,,50.91,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701254,CDM,,OUTPATIENT,,,40.02,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701303,CDM,,OUTPATIENT,,,30.3,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701304,CDM,,OUTPATIENT,,,592.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701305,CDM,,OUTPATIENT,,,900.9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701307,CDM,,OUTPATIENT,,,23.58,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701326,CDM,,OUTPATIENT,,,2.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701346,CDM,,OUTPATIENT,,,46.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701362,CDM,,OUTPATIENT,,,97.68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701363,CDM,,OUTPATIENT,,,155.04,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701391,CDM,,OUTPATIENT,,,64.98,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701414,CDM,,OUTPATIENT,,,40.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701415,CDM,,OUTPATIENT,,,27.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701416,CDM,,OUTPATIENT,,,42.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701417,CDM,,OUTPATIENT,,,40.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701418,CDM,,OUTPATIENT,,,59.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701419,CDM,,OUTPATIENT,,,54.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701464,CDM,,OUTPATIENT,,,715.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701478,CDM,,OUTPATIENT,,,12.63,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701484,CDM,,OUTPATIENT,,,137.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701527,CDM,,OUTPATIENT,,,140.46,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701528,CDM,,OUTPATIENT,,,144.81,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701557,CDM,,OUTPATIENT,,,409.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701558,CDM,,OUTPATIENT,,,409.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701559,CDM,,OUTPATIENT,,,409.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701560,CDM,,OUTPATIENT,,,155.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701561,CDM,,OUTPATIENT,,,155.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701569,CDM,,OUTPATIENT,,,12.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701571,CDM,,OUTPATIENT,,,176.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701582,CDM,,OUTPATIENT,,,31.05,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701590,CDM,,OUTPATIENT,,,106.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701641,CDM,,OUTPATIENT,,,311.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701677,CDM,,OUTPATIENT,,,242.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701678,CDM,,OUTPATIENT,,,35.73,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701679,CDM,,OUTPATIENT,,,38.19,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701715,CDM,,OUTPATIENT,,,133.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701772,CDM,,OUTPATIENT,,,46.65,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701779,CDM,,OUTPATIENT,,,26.49,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701830,CDM,,OUTPATIENT,,,3.78,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701831,CDM,,OUTPATIENT,,,3.84,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
MED / SUR - STERILE SUPPLY,,,272,RC,93701832,CDM,,OUTPATIENT,,,3.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
750 MG CEFTRIAXONE,,,636,RC,589029,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
8 MG DEXAMETHASONE,,,636,RC,589038,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589085,CDM,,OUTPATIENT,,,0.61,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
80MG TRIAMCINOLONE,,,636,RC,589101,CDM,,OUTPATIENT,,,48.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
88 MG HYALURONAN,,,636,RC,589114,CDM,,OUTPATIENT,,,675,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
IM INJECTION - TIXAGEVIMAB AND CILGAVIMAB,,,760,RC,7212021,CDM,,OUTPATIENT,,,301,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION KETOROLAC TROMETHAMINE PER 15 MG,,,983,RC,7046139,CDM,,OUTPATIENT,,,9,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
INJECTION. BUPIVICAINE. NOT OTHERWISE SPECIFIED. 10MG,,,636,RC,J0665,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0010 HEPATITIS B ADMINISTRATION CHARGE,,,771,RC,VACG0010,CDM,,OUTPATIENT,,,71.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0105 COLONOSCOPY HIGH RISK,,,960,RC,G0105,CDM,,OUTPATIENT,,,516,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT 30 MINUTES CHARGE,,,942,RC,7046153,CDM,,OUTPATIENT,,,117,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0108 DIABETES MANAGEMENT TREATMENT PER 30 MINUTES,,,942,RC,G0108,CDM,,OUTPATIENT,,,121,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0109 DSME GROUP CHARGE,,,942,RC,G0109,CDM,,OUTPATIENT,,,33,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0121 COLORECTAL CANCER SCREEN,,,960,RC,G0121,CDM,,OUTPATIENT,,,516,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0296 COUNSELING VISIT TO DISCUSS NEED FOR LUNG CANCER SCREE,,,960,RC,G0296,CDM,,OUTPATIENT,,,156,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0439 ANNUAL WELLNESS VISIT/SUBSEQUENT,,,960,RC,G0439,CDM,,OUTPATIENT,,,145,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G2025 - SYNCHRONOUS TELEMEDICINE SERVICE RENDERED VIA REAL-T,,,960,RC,G2025,CDM,,OUTPATIENT,,,188.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210032,CDM,,OUTPATIENT,,,1547.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210033,CDM,,OUTPATIENT,,,1547.06,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GASTROINTESTINAL SERVICES - GENERAL,,,750,RC,7210054,CDM,,OUTPATIENT,,,355.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GEN ANES SUPPLY,,,370,RC,801003,CDM,,OUTPATIENT,,,549,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
GUIDE WIRE,,,272,RC,62102628,CDM,,OUTPATIENT,,,72,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
HALOPERIDOL,,,636,RC,589057,CDM,,OUTPATIENT,,,26.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EA018 APH PLTS ACDA IRR LR BM>=36H 3,,,300,RC,7010638,CDM,,OUTPATIENT,,,1841,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
EST. PATIENT LEVEL 2,,,519,RC,G0463,CDM,,OUTPATIENT,,,268.83,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ETHYL CHLORIDE TOPICAL,,,250,RC,589054,CDM,,OUTPATIENT,,,0.35,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BLOCK SUPPLY,,,279,RC,801001,CDM,,OUTPATIENT,,,294,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
BUPIVACAINE-EPINEPHRINE,,,636,RC,589167,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISP WOUND SUCT DRSG/ACCESS,,,272,RC,93702042,CDM,,OUTPATIENT,,,109.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DISPOSABLE CANISTER FOR PUMP,,,278,RC,62102066,CDM,,OUTPATIENT,,,219.96,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE OT CONTRACT,,,990,RC,7081028,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE SPEECH CONTRACT,,,990,RC,7082019,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DR. LEVESQUE ST CONTRACT,,,444,RC,7082028,CDM,,OUTPATIENT,,,17.51,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - RADIOLOGY,,,255,RC,70421010,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,7040159,CDM,,OUTPATIENT,,,11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,62102137,CDM,,OUTPATIENT,,,218.1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,72101081,CDM,,OUTPATIENT,,,120,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011001,CDM,,OUTPATIENT,,,993.21,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,74011010,CDM,,OUTPATIENT,,,3255,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
DRUGS - REQUIRING DETAIL CODING,,,636,RC,J7318,CDM,,OUTPATIENT,,,31.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
FOAM DRG <=16 SQ IN W/BORDER,,,270,RC,62103370,CDM,,OUTPATIENT,,,64.62,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0008 INFLUENZA ADMINISTRATION CHARGE,,,771,RC,VACG0008,CDM,,OUTPATIENT,,,71.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
G0009 PNEUMOCOCCAL ADMINISTRATION CHARGE,,,771,RC,VACG0009,CDM,,OUTPATIENT,,,71.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PAD CAUTERY GROUNDING MEDTRONIC,,,272,RC,62101107,CDM,,OUTPATIENT,,,7.11,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,7040160,CDM,,OUTPATIENT,,,5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103027,CDM,,OUTPATIENT,,,53.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,62103029,CDM,,OUTPATIENT,,,20.07,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401016,CDM,,OUTPATIENT,,,6.48,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401017,CDM,,OUTPATIENT,,,142.14,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401018,CDM,,OUTPATIENT,,,5.82,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401019,CDM,,OUTPATIENT,,,148.47,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401020,CDM,,OUTPATIENT,,,99.66,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401021,CDM,,OUTPATIENT,,,28.32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70401022,CDM,,OUTPATIENT,,,256.08,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY,,,250,RC,70421013,CDM,,OUTPATIENT,,,565.44,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
PHARMACY - OTHER,,,259,RC,MISC PHARM,CDM,,OUTPATIENT,,,1,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ADULT PSYCH,,,124,RC,PSYCH,CDM,,INPATIENT,,,2200,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: BED HOLD,,,180,RC,BEDHOLD,CDM,,INPATIENT,,,307.97,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: CHILD PSYCH,,,124,RC,PSYCHC,CDM,,INPATIENT,,,2200,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: ICU,,,200,RC,ICU,CDM,,INPATIENT,,,3666,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: MED/SURG,,,120,RC,Med/Surg,CDM,,INPATIENT,,,1686,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY,,,170,RC,Nursery,CDM,,INPATIENT,,,1552.21,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: NURSERY WITH MOTHER,,,179,RC,NURSMOM,CDM,,INPATIENT,,,1494.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ROOM/BED: OB,,,122,RC,OB,CDM,,INPATIENT,,,1765.42,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
ANCHOR/SCREW BN/BNTIS/BN,,,278,RC,62106166,CDM,,OUTPATIENT,,,720,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0702,CDM,,OUTPATIENT,,,15.45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J0775,CDM,,OUTPATIENT,,,89,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J1200,CDM,,OUTPATIENT,,,16,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2315,CDM,,OUTPATIENT,,,5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2920,CDM,,OUTPATIENT,,,32,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J2930,CDM,,OUTPATIENT,,,76,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7300,CDM,,OUTPATIENT,,,513,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLINIC,,,983,RC,J7325,CDM,,OUTPATIENT,,,51.36,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
CLONIDINE,,,250,RC,589033,CDM,,OUTPATIENT,,,0.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM,,,636,RC,589130,CDM,,OUTPATIENT,,,6436.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
COLORECTAL CANCER SCREENING FLEXIBLE SIGMOIDOSCOPY,,,750,RC,7210020,CDM,,OUTPATIENT,,,2909,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.15 ML EPINEPHRINE,,,636,RC,589053,CDM,,OUTPATIENT,,,375,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
.30 ML EPINEPHRINE,,,636,RC,589052,CDM,,OUTPATIENT,,,432.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.25% BUPIVACAINE,,,636,RC,589028,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
0.5% BUPIVACAINE,,,636,RC,589027,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 EA COPPER IUD,,,636,RC,589034,CDM,,OUTPATIENT,,,1239,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 GM CEFTRIAXONE,,,636,RC,589032,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1 ML EPINEPHRINE,,,636,RC,589051,CDM,,OUTPATIENT,,,45,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 10ML LIDOCAINE,,,250,RC,589074,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1% 20ML LIDOCAINE,,,250,RC,589073,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1.25 MG ALBUTEROL,,,636,RC,589021,CDM,,OUTPATIENT,,,0.85,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
1000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589036,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG DEXAMETHASONE,,,636,RC,589037,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10MG TRIAMCINOLONE,,,636,RC,589098,CDM,,OUTPATIENT,,,24.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
10ML SINGLE DOSE EOVIST,,,255,RC,70441001,CDM,,OUTPATIENT,,,40.23,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12 MG BETAMETHASONE ACETATE,,,636,RC,589026,CDM,,OUTPATIENT,,,68,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
12.5 MG DIPHENHYDRAMINE,,,636,RC,589043,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
125 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589087,CDM,,OUTPATIENT,,,1.17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
15 MG KETOROLAC,,,636,RC,589069,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
150MG/1ML SUSP MEDROXYPROGESTERONE,,,636,RC,589080,CDM,,OUTPATIENT,,,244.8,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
16 MG INJ SYNVISC,,,636,RC,589112,CDM,,OUTPATIENT,,,51.38,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 MG DEXAMETHASONE,,,636,RC,589040,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2 PUFFS,,,250,RC,589022,CDM,,OUTPATIENT,,,53.7,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 20ML LIDOCAINE,,,250,RC,589071,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2% 5ML LIDOCAINE,,,250,RC,589072,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2.5 MG ALBUTEROL,,,636,RC,589020,CDM,,OUTPATIENT,,,0.4,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589083,CDM,,OUTPATIENT,,,1.71,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
2000 MCG CYANOCOBALAMIN (B12) INJ,,,636,RC,589035,CDM,,OUTPATIENT,,,16.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
20MG TRIAMCINOLONE,,,636,RC,589099,CDM,,OUTPATIENT,,,24.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG DIPHENHYDRAMINE,,,636,RC,589042,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
25 MG SODIUM HYALURONATE,,,636,RC,589126,CDM,,OUTPATIENT,,,498.25,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
250 MG CEFTRIAXONE,,,636,RC,589030,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
3 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589024,CDM,,OUTPATIENT,,,17,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG ELLA,,,250,RC,589110,CDM,,OUTPATIENT,,,46.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG HYALURONAN,,,636,RC,589113,CDM,,OUTPATIENT,,,502,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG KETOROLAC,,,636,RC,589068,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
30 MG SODIUM HYALURONATE,,,636,RC,589127,CDM,,OUTPATIENT,,,502,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
300MCG RHOPHYLAC,,,636,RC,589094,CDM,,OUTPATIENT,,,351,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
380MG NALTREXONE,,,636,RC,589115,CDM,,OUTPATIENT,,,7.53,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG BETAMETHASONE SODIUM PHOSPHATE,,,636,RC,589025,CDM,,OUTPATIENT,,,22.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG DEXAMETHASONE,,,636,RC,589039,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
4 MG ONDANSETRON,,,636,RC,589088,CDM,,OUTPATIENT,,,24.2,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE ACETATE,,,636,RC,589084,CDM,,OUTPATIENT,,,0.86,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40 MG METHYLPREDNISOLONE SODIUM,,,636,RC,589086,CDM,,OUTPATIENT,,,2.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
40MG TRIAMCINOLONE,,,636,RC,589100,CDM,,OUTPATIENT,,,24.5,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
48MG/6ML HYLAN G-F 20,,,636,RC,589063,CDM,,OUTPATIENT,,,2465.28,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
50 MG DIPHENHYDRAMINE,,,636,RC,589041,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
500 MG CEFTRIAXONE,,,636,RC,589031,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
52 MG LEVONORGESTREL,,,636,RC,589070,CDM,,OUTPATIENT,,,1014.15,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
6 MG BETAMETHASONE ACETATE SODIUM PHOS,,,636,RC,589023,CDM,,OUTPATIENT,,,34,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG KETOROLAC,,,636,RC,589067,CDM,,OUTPATIENT,,,15.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60 MG SODIUM HYALURONATE,,,636,RC,589123,CDM,,OUTPATIENT,,,1890,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN
60MG TRIAMCINOLONE,,,636,RC,589102,CDM,,OUTPATIENT,,,48.75,2465.28,WELLCARE,WELLCARE,,,,2289.75,,,,CODE COMINATION NOT COVERED BY THIS PLAN